Business Rules Analysis
of the VA and Constitutional Law
The VA's interpretation of the law separates eligibility from the actual distribution of benefits. In other words, being eligible for benefits is not a guarantee of benefits. The word benefits is an overloaded term that has a slightly different meaning in different contexts. The rules that govern VA benefits start with Constitutional Law. The VA administration interprets the law to create Department regulations used to conduct the business operations defined by the law. Within the Department are many business operational levels, for each level the regulations require more context-specific guidelines. For each operation to operate as required by the law, the VA interprets regulations into policies. Then for the business execution of operations, the policy becomes procedures. The business implementation for the VA begins with the law, then interpretations for regulations, then the policy, the procedures. If the three levels of interpretation are accurate, a procedure must be a substantiated as a valid interpretation of the law. None of the VA documents are the Law. The VHA has created regulations that the VHA claims to be "the Law" but in fact, the documents are not the law.
The VA's use of the term benefits is confusing. However, there is a business model that is the same model as VA benefits. The Department of Veteran Affairs is one of the President's fifteen Executive Agencies. As an executive department, every agency has an account report. Standard accounting practices use journals listing entries as a named item or service with the associated cost. A journal entry is a fee for an item or service. This pairing, service, and fees, is the same pairing the VA calls benefits. An accounting journal classifies the journal entry as a valid financial report category. All classification systems impose eligibility restrictions separating items that belong to a category from those items that cannot belong in the category. The business model for an accounting item is eligible(item and cost). The VA model for benefits is the same eligible(service and fee) where service and fee are named a benefit. The VA may acknowledge a veteran is eligible for a service but procedures qualify fee allowance. The separation of services and fees by procedure control over fees complicates veteran's medical expense coverage.
The VA sent a denial that said "by law" the VA cannot pay the ER copay medical expense. Rather than accepting the denial as fact, I wanted to know what was the actual wording in the law. My understanding that by being eligible for VA benefits, the medical treatment would be covered by the VA. We did not know that the VA, before the fact, misrepresents itself about ER benefits. When the VA sends a denial, the veteran can appeal the decision. To make an appeal, the veteran must show a reason to reverse the denial. To find the appeal reason meant finding the exact part of the law the VA used a reason for the denial. As an Americal citizen for 70 years, I am embarrassed that I did not know how Constitutional Law is part of our government.
The VA has helped me and others. Sometimes a situation happens that is in conflict with a reasonable person's thinking. In the case of payouts for ER treatment at a non-VA facility, the VA created regulations not substantiated by Law.
38 USC Veteran's Benefits Chapter 38 USC 1725 Reimbursement for emergency treatment is a good business rule with one major exception, the two-year requirement for (B) the veteran received care under this chapter within the 24-month period preceding the furnishing of such emergency treatment.
The real problem with 38 USC 1725 is the VA contrived regulations not substantiated in the Law. Under the Law, the VA either pays the provider or reimburses the veteran. All generally accepted business practices require an invoice from the provider. While the Law does not use the term invoice, the Law does define payouts. In a follow the money analysis, the invoice is a benchmark document. The VA can accept invoices from either the provider or the veteran. The Law defines payout to the veteran as reimbursement. In VA regulations the VA incorrectly uses the word reimbursement to mean direct pay the provider. The word reimbursement means "to pay back.” Black's Law dictionary further explains "It means to make return or restoration of an equivalent for something paid, expended, or lost; to indemnify or make whole." The Law is clear either pay the provider or reimburse the veteran. In order for the veteran to invoice for reimbursement, the veteran must first pay the provider.
The VHA has denied many many veterans with the statement "VA has no legal authority pay to a veteran’s cost shares, deductible, or copayment associated with OHI" This statement is complete bullshit. The Law states "The Secretary may not reimburse a veteran under this section, Limitations on Reimbursement, for any copayment or similar payment that the veteran owes the third party or for which the veteran is responsible under a health-plan contract." The statement prohibits the veteran from double dipping by claiming the veteran's OHI payment as a pre-paid amount by the veteran. The veteran is responsible for the health plan contract. If the health plan contract does pay some of the medical expense, the Law does not allow the veteran to include that payment for reimbursement.
Somehow, some way, somebody at the VA twisted the use of copay to mean the veteran's payout responsibility. Copay and coinsurance mean two payer's, the insurance and the patient. The veteran's unpaid medical expense is still the responsibility of the VHA.
The Law makes it impossible for the veteran to prepay the provider. Under the Law, "establish the maximum amount payable under subsection" sometimes called maximum allowed amount (MAA). The VHA does not provide an explanation of benefits that explains the MAA.
If the MAA is the same as the Medicare fee for a medical service, the veteran could overpay the provider. If the veteran pays the provider a fee higher than the MAA, the VA cannot by Law reimburse the overpaid amount. The VA regulations for ER treatment at a non-VA facility for MAA, EOB, and reimbursement is bullshit.
I have not seen an animal shit on top of shit. I have seen different dung piles. The VHA in its regulations for non-VA facility ER care has managed to pile shit on top of shit.
If the VA pays the provider the MAA, the payment exhausts further provider fees for the same medical service. As a veteran the most out-of-pocket expense a veteran should ever pay the provider is the MAA. Without a VHA EOB, neither the provider nor the veteran can determine the correct invoice or payout. The absence of a VHA EOB is the stinkweed in the bullshit.
Perhaps the worse pile of bullshit is the VHA breach of its judiciary trust on the Goodwill Grant. If a veteran has a private health plan contract for medical insurance, The Goodwill Grant is the veteran's volunteered permission of the veteran's private health insurance for VA's direct cost recovery at VA facilities. 38 U.S. Code § 1729 - Recovery by the United States of the cost of certain care and services. The Goodwill Grant does not give the VHA permission to use the terms of private insurance with other providers. Because the Goodwill Grant has terms for copay and deductibles, the VHA uses its knowledge of the terms to demand the provide insurance EOB from the provider. This demand is bureautic extortion refusing to pay without an EOB. The provider has the legal responsibility to reconcile other party payouts before invoicing the VA.
In the case of non-VA facility ER treatment, the VHA has no legal authority to demand an EOB from the provider. The provider, the patient, and the insurance company have a private contract. The VHA cannot demand information about the private contract. If the veteran invoices for reimbursement, the veteran is responsible for the reciliation of the other payer payout. The VHA has no legal authority to demand the EOB from the veteran. If the VHA suspects the veteran or the provider submit fraudulent invoices, the VHA has the responsibility to report to the legal authority.