Sunday, August 25, 2019

38.1725: Information Modeli

38 USC 1725 as an Information Model

38 USC 1725 is the Law about the business relationships with veterans, DVA, community providers, private insurance and others.. This information model describes the business relationships.

Technical Background

Dictionary: An information model in software engineering is a representation of concepts and the relationships, constraints, rules, and operations to specify data semantics for a chosen domain of discourse. Typically, it specifies relations between kinds of things, but may also include relations with individual things. It can provide a sharable, stable, and organized structure of information requirements or knowledge for the domain context.

Ontology Models – Formal structures (classification systems, assemblies, and parts, language)

Affinity Models – Abstract structures (diagnostic, association, disassociation, discrimination, acceptance)  

Social Models – Tribe structures (law, group dynamics, bias influences, behavior expectation, linguistics)

Modeler Skills – Psychology, Information Science, Data Systems, Computer Science, Business Science (contract law, accounting, finance, economics, marketing), Domain Knowledge (medical, manufacturing, service, sales), Systems Analysis & Design, Communications, Business Arts (writing, speaking, management, social networks), Negotiation Reduction.   

Information Bridges 

Every domain has collective and subjective models particular to the domain. Engineering, science, teaching, government, family, medicine, transportation, recreation, commerce has different information modals inclusive to the domain. In the theater domain is serval well-understood information elements.  During the analysis of other domains, often the theater elements functions can be useful for affinity identification. Sometimes in domain analysis, information modelers use the theater element names provide a concept bridge into the domain under analysis. As the information model matures, the domain name replaces the theater name.

Theater
Function
Business
Actors
Participants
Principals
Role
Activity
Party
Play
Interaction
Contract
Property
Things of Interest
Deliverables, Services
Stage
Environment
Law
Director
Goal Insight
Operations
Audience
Client
Customer
Tickets
Demand for property
Invoice
Performance
Production
Payout
Writers
Title
Owners

Watchwords:

During the analysis process, word terminology can be overloaded based on many factors.  If the analysis is specific to a domain, the terms can still be overloaded. Even two people can misunderstand each other. Nature grants people the ability to build the mind’s information model. As a result, every person’s information model is specific to the person.  Watchwords are terms the modeler use to as alerts that may affect the model. In language, word order defines syntax elements. Each word has a definition, order relationships together with definitions create communication meaning. Watchwords signal information semantics.

Common Terminology:

  • Wherever the term money appears, the term means value, use, and title.
  • The insured hires the insurance company, insurer, to limit the payout liability of the insured. When the insured pays premiums for the insurance policy, the premium provides an obligation on the insurer with a guarantee the insurer will transfer title of the insurer’s money to the insured. Sometimes the insured will delegate authority to the insurer to pay money to the entity the insured has an obligation.
  • Agency is the most common type of contract for consumers.
  • Invoices and payments are contract instruments identifying money transfer.
  • A medical episode-of-care can have one or more medical expenses which is a fee for a medical service.
  • Grantor and grantee are actors in a title transfer.
  • Business accounting is a recording of money use.
  • Assets = Liability + Owner Equity (Revenue – Expenses) (a.k,a Net Assets)
  • Trade Þ Purpose Þ Needs & Wants Þ Contract
  • Data Þ Value Þ Meta-data Þ Roles
  • Program Þ Process Þ Schedule Þ Property Þ Value
  • Value Þ Quantity & Quality
  • Production Þ Cost D Quality D Schedule balance
  • Title Þ Ownership & Asset ~ copyright, trademark, procession
  • Follow-the-Money Þ Process Þ Trade Þ Money
  • Payment Þ Money
  • If exist Þ then Þ else
  • Syntax (structure) Þ Semantics (meaning)
  • Joint and Disjoint  Þ In contracts, the two principals (A & B ) have a joint agreement. When a activity involves more than two principals (A,B, C) . A & B and B & C are two separate joint agreements.. A & C are disjoint with no common agreement.  B may supply parts to A. C may supply parts to B, that B uses to make parts for A. 

Medical Business Terms

  • Medical Expense = fee & medical service
  • An Episode of Care Þ Medical Expense & Qualification {Edibility, Time, Purpose}
  • Authorize Þ Permission to transfer title
  • Reimbursement = A principal’s payback to a principal for money paid the principal paid on behalf of a contract.
  • Copayment = the policy amount insurer pays and and insured each agree to pay for  medical fee. 
  • Deductible = The insurer’s time-based threshold amount of medical fees the insured pays before the insurer’s payout.
  • Premiums = the direct cost of an insurance policy. Usually an employer pays some and the employee pays some.
  • Insurance = a contract, policy, between the insured and the insurer whereby the insurer guarantees liability protection for the insured. 
  • Insurance payout = the insurer's liability protection amount given to the insured for purposes of paying the liability. 
  • Patient = the person receiving medical treatment at a provider.
  • Provider = the person or organization supplying medical treatment.
  • In-network provider =  an agreement between the provider and the insurance copy on cost for medical expenses.
  • Explanation of Benefits =  the insurer's calculation report based the in-network agreement detailing the copayment amounts.
  • Provider Invoice =  a detail list of the treatment fees and services requesting patient payment
  • Invoice Payment =  the money paid against the invoice

Veteran:

  • Paragraph 38 U.S. Code § 1725. Reimbursement for emergency treatment Statue (a)(2) instructs (assigns) the VA either pay the veteran or pay the provider.
  • Title USC 38 Veterans’ Benefits is a benefit grant from Congress to every veteran and an authorization for Veteran’s Administration to be Congress's Agent to use the Federal Budget for veteran's benefits payment. 
  • 38 USC 1725 Contracts
  1. VA & Veteran  ~ role: Benefit Payout
    1. VA & Provider ~ role: Veteran assigns VA to pay medical expense treatmentPatient & Provider ~ role: treatment & payment responsibility
    2.  Provider & Insurance Company ~ role in-network agreement
    3. Patient (insured) & Insurance Company (insurer)
Note: the VA does not have a contract with an insurance company at non-VA faculty therefore not rights to policy terms. The VA is disjoint from the insurance company.
  • Maximum Allowable Amount = Medicare fee

  • Information Generation Distortion =  The VA's multiplication of business instructions causes errors in compliance with the Law:   Law > Regulations > Policy > Procedures
  • The effect is the whisper game:




Friday, August 23, 2019

Multiple Sclerosis: Letter to Jimmie Heuga

Happy Birthday Jimmie
Sept 22, 2012


Dear Jimmie,
This is a letter I wrote to Jimmie Heuga, ski racer, MS champion, my pedal partner on my first 150 Bike MS ride. His was the inspiration for Can    Do MS in Vail. September 22 was Jimmie’s birthday and he died February 2010.  Two years later, on his birthday, I did a bike ride that was a challenge for me. This is a letter I wrote to him about the ride.    

Dear Jimmie,

This is a letter I wrote to Jimmie Heuga, ski racer, MS champion, my pedal partner on my first 150 Bike MS ride. His was the inspiration for Can    Do MS in Vail. September 22 was Jimmie’s birthday and he died February 2010.  Two years later, on his birthday, I did a bike ride that was a challenge for me. This is a letter I wrote to him about the ride.  
  
On Saturday the 22nd, 4 friends and I rode a bicycle ride I tagged as the CanDo 50.  The ride heads west from Loveland. At the base of the foothills, the route turns north to Mansoville, which begins the climbs over the Horsetooth Reservoir Hills. Just before Bellvue is Bringham Hill Road that heads back east to Fort Collins.  At Overland Trail, we head south on streets and trails to Loveland.

At the start, the weather was slightly hazy and cool. I admit I was worried about doing this ride because I did not know if I could climb the six Horsetooth hills in the same ride. While the hills are not much by Colorado climbs, to me each represents overcoming MS challenges.  When I started riding to improve my overall health and put my MS on notice that I was in charge, I remember each of those hills because many times I had to get off the bike and walk up them.

By mid-morning, the haze is lifting and the two of the west Horsetooth hills are finished. Because I trained on those hills, claiming them was still work, but not difficult.
A turn north and across the dam, the forth ill is a short steep climb above the reservoir. Silly, how sometimes just the thought of a thing will block success. Months before today, I walked that hill at least five times or more. At the base, looking up I said to myself, “That’s not much of a hill, what are you worried about?” Sure enough Jimme, it was not much of a hill today. Next was hill 5, it is long and steep, and provokes heavy breathing, but the MS never fatigued. The downhill is great  Hill six is a bump but it marks the turn back to Loveland.

I am sure you remember, that climbing hills with MS takes special conditioning, the descent takes even more conditioning. Because downhill is faster, it requires faster reaction times and coordination. It’s the same for all riders, but for MS’ers, fatigue is riding out in front looking for a way to cause trouble.   You get to the top, legs are burning, lungs gasping, heart-pounding, arms and hands weak from gripping the handlebar, and you see that downhill. In quick order, not only does the ride focus change, but you must shift from low gears to high gears, test brakes, relax tense muscles, change line-of-sight focus, switch mental fears, watch for obstacles, plan a safe path, adjust riding positions, anticipate curves, heighten the  back sense, and then look for that downhill freedom path to make the ride. 

 For me as an MS rider, both the climb and the descent have MS challenges. MS  has no place is during the downhill ride. The MS cannot catch me there. I let go of the struggles, trust my bike, tuck down, smile and laugh at the fatigue. 

By noon, my friends peeled off, each heading home. That left three miles to finish the ride by myself. This was a great day because those last minutes gave me time to reflect on the ride and remember the one time I met you, the day you signed my helmet as my first pedal partner. As an MS Ambassador, I told that story many times and the importance of fighting MS in many ways.

At the end, the CanDo ride was 47 miles. I rode the 6 hills without walking a single one.  After getting back to the start, I still had a couple of miles to get home. No problem.  We had a great ride pedal partner.

Happy Birthday, Jimmie!






Tuesday, August 20, 2019

Veteran: Veterans' Administration is Breaking the Law


This post is about the VA creating regulations that are not compliant with the Law, engaging in acts of bureaucratic extortion and bureaucratic racketeering. -- Ok, I am not a lawyer, so maybe the terms are expressions of frustrations. This article explains my use of the terms.

Breaking the Law

When a veteran has ER treatment at a non-VA facility, the VA will either pay-the-provider or reimburse-the-veteran. If the veteran does not have private insurance, the VA accepts the provider's bill. If the veteran has private insurance, that has copays and deductibles for the episode-of-care, the VA claims by Law the VA cannot pay the copays and deductibles. No statute in Law supports that claim.

On September 11, 2017 at 3 AM, my wife, an Army vet, woke with pains in her chest.  The nearest VA hospital is in Cheyenne, more than an hour away. The VA directs veterans who have an emergency condition to seek treatment at a community provider.  I took my wife to the nearest ER. The diagnosis was gallbladder problems. We followed all the VA protocols for adverse conditions.  Two weeks later a surgeon at the VA removed the gallbladder.

We followed all the reporting protocols expecting the VA would consider the community hospital treatment the same as if the treatment occurred at VA facility. We give the VA permission to use our private insurance for cost recovery at VA facilities. We did not expect the VA to use the information about the insurance to deny the ER benefits. A few weeks later, the hospital sent a statement for $3600 which is the $3500 insurance deductible and some patient copay. Because the VA is the primary provider, a $3500 deductible keeps the premiums down, yet still provide a cost recovery threshold.

Next, a letter from the VA arrived denying the ER expenses stating, "By Law, the VA cannot pay other health insurance deductibles and copays." The VA's letter shocked us. We followed protocol. We give VA cost recovery permission, the ER was not considered the same as at a VA facility, and the VA used the information about our private insurance with a third party. I thought we did everything right, yet the VA said we did not. I needed to understand why.  Next started months of study.

Until the VA's denial, I was ignorant about Contsutinal Law and executive department regulations. Starting with an empty mind has rewards, although, acquiring information the mind will postpone the rewards. Once in awhile, something happens that trips a mental trigger and all the pieces of information blend from chaos into order.

US Government
As Americans, we know about Congress, the President, the Supreme Court. Our mental model includes Representatives, Senators, Judges, and the Federal Bank. Most citizen federal government interactions are with one of the
And we hear about law, regulations, and procedures. Until the VA's denial, my knowledge of government was intuitive. As I learned more about the Federal Government, the more I felt uneducated. United States Code (USC), the Law, defines the executive departments, operations.  Each of the department's code has a number and a title. The VA's title is 38 USC Veterans' Benefits.

The US Federal Budget is the corner post of government that enables government operations. Constitutional law is a business plan that directs operational activity for spending the Budget's money.

Other laws like contract law and privacy supersede and enable the Code. When the Code uses words like pay,  payment or reimburse, these words immediately invoke business processes and the laws related to business.




MS Inside-Out: History of MS

MS Inside-Out: History of MS

  • 1399, 1st diagnosed case of MS
           Saint Lidwina of Holland
           1380-1434 
           Diagnosed with MS at 19 
           MSer for 34 years!  
  • May 1, 1945 
          a New York Times classified advertisement read:
        “Multiple Sclerosis. Will anyone recovered from it 
          please communicate with the patient." 
             Placed by Miss Sylvia Lawry, Founder NMSS
  •      March 11, 1946   
           The National Multiple Sclerosis Society founded. 
  •     1993 - first disease-modifying therapy
     
  •     2020 Still no cause, no cure.

MS Inside-Out: Your are my HERO

YOU ARE MY HERO

When I give MS Ambassador talks, I always thank those listening with this recognition:

When I rode my first Bike MS 150, wearing my first “I ride with MS” jersey, riders passing would call out “You're my hero.”  After about 100 miles, I realized, I am not the hero, but those out here riding to support the cure for MS are my heroes. 

After thinking about heroes, I realized “hero” is an 
acronym for Help Everyone, Respect Others.

When you give time, talent, treasure and tenacity, you show respect. For me, tenacity is the most important. 
Never give up.

Each of you is my hero.

Thank you

Monday, August 19, 2019

MS Inside-Out: Concurrent Complex Syndrome


Concurrent Complex Syndrome

Inside-Out:

For years I looked for a term that groups all the different interconnected complications with MS. In my "MS from the Inside-Out" study, an MS attack is a type of trauma. The factors of trauma are injury, emotional, social and disability. The term "Complex Trauma Syndrome" acknowledges the complicated interdependent trauma factors. An MS attack inherits some characteristics from complex trauma syndrome plus adds the labyrinth effects from "Complex Fatigue Syndrome” caused by the physical, neurological and neuropsychological MS wounds. By thinking of the "MS syndrome"   as a layered complex group of symptoms whose characteristics are distinguished by inherited or innate. For example, the MS emotional symptom of an outcast is inherited but denial is innate. However, both outcast and denial are each complex syndromes within the group.

The origin of a complex syndrome happens as the trigger from some event. Power engineering uses the term dark start to describe the process uses to restart the main power generation turbines following a grid backout.  To start the big turbine requires a motor strong enough to initiate turbine movement. Then another motor is used to start the turbine starter motor. And another motor starts the motor that start the motor that starts the turbine starter motor. When some flips a switch to turn on a room’s light bulb, the light’s glow happens as the result of a dark start switch. A simple power on switch has many dependencies on science, physics, chemistry, engineering, craftsmanship, architecture and more including the biomechanics of the hand, human physical prowess, neurological coordination and the neuropsychological wherewithal that creates a plan to turn on the switch.  Sometimes, all that is necessary to intuitively attribute a dark start as a common event. From the room’s perspective, the dark start trigger occurred at the flipping of the switch.

Every injury does not exist until a black start trigger event happens. In MS, the explanation “no known cause” means science has not found the true dark start source for MS symptoms. However, science does know the MS injury begins with a wound from the immune system removing myelin. This injury is the clinical dark start source that in turn causes wounds.  

Concurrent Dissonance Disorder – In wellness, concurrent dissonance disorder is multi-factor physical, mental or social disorders occurring near-simultaneously caused by a trauma event. A disorder is an injury where the injury provokes a wound that disrupts or creates an injury that affects other orders.

Imagine playing the guitar. Each string's normal order rests in the air quiesced and stretched in tune. As the pick strikes the string, the sting becomes disordered producing harmonic vibrations. The string's disorder provokes dissonance in the air causing the air to be disordered to be heard as sound. When the pick strikes several strings, the near-simultaneous disorder from each string produces a complex syndrome of sounds called music.

Monday, August 12, 2019

Pysc: The 40 Human Senses

The 40 Human Senses

What are the senses?

To answer what is a sense the first question is why do senses exist in animals? While all-natural living phenomena may have senses, the human phenomena with its brain can react to diverse sense stimulus.

A sense is a particular natural neurological (CNS and PNS) facility producing neuropsychological (thinking) representation models.  These sense models are self-activated which, in turn, generate other models. Each generated model maintains traits from the parent. A generated sense model may have one or more parents.

Nociceptive pain

Examples of nociceptive pain are a cut or a broken bone. Tissue damage or injury initiates signals that are transferred through peripheral nerves to the brain via the spinal cord. Pain signals are modulated throughout the pathways. This is how we become aware that something needs attention.

Neuropathic pain

Neuropathic pain is pain caused by damage or disease that affects the nervous system. Sometimes there is no obvious source of pain, and this pain can occur spontaneously. Classic examples of this pain are shingles and diabetic peripheral neuropathy. It is pain that can occur after nerves are cut or after a stroke.
The fundamental survival actions are flight, fight, fawn, fade, finesse, and freeze.  The precursor to each of these actions is the anxiety sense signal. The signal prompts consequence learning or memory recalls that generates an appropriate action. Anxiety itself may not be a natural sense and most likely is the result of precursor chemistry from the 41 natural senses.
Process is the capability to build sense models. Learning is high order application of process models.  A process sense accepts signals from other senses.  Imagine a set of balloons inflated to various sizes lined adjacent to each other in a straight line. Each balloon represents a process sense. 

The purpose of the natural senses is survival. Each sense can trigger an anxiety signal that demands attention.

The wonderful characteristics about natural senses is their harmony state.  Each operates within a disturbance tolerance without triggering a reactive or executive action. Each sense’s harmony state is always active. Each maintains operational boundaries proprietary to survival persistence.  When a condition occurs to compromise the boundaries and threatens persistence, then the compromised sense can be corrected to its harmony state either by predefined reactive means or by getting assistance through raising an anxiety flag. While a reactive correction, like pulling a hand from a burning stove, can happen immediately, an anxiety flag also signals an urgency demand. An accidental trip that causes a fall would have an anxiety urgency demand evoking other body systems into immediate action. Whereas, reading a book would have less urgency.



The Human Senses
Qualitative
The 5 environment senses:
  • sight
  • sound
  • taste
  • touch
  • smell
The 10 wellness senses:
  • movement (still)
  • hunger (glut)
  • thirst (want)
  • safety (threat)
  • waste (preserve)
  • rest (active)
  • strength (weakness)
  • flexibility (rigidity)
  • endurance (exhaust)
  • heat (chill)
The 7 social senses:
  • process
  • perception
  • trust
  • communication
  • community
  • habitat
  • acceptance (rejection)
The 9 emotional senses:
  • respect (contempt)
  • peace (war)
  • happiness (agony)
  • love (indifference)
  • hate (aversion, concern)
  • faith (doubt)
  • fear (confidence)**
  • hope (despair)
  • empathy (detachment)
The 11 intrinsic senses:
  • awareness
  • fullness
  • thermoception
  • oxygen levels
  • vomiting
  • magnetoreception*
  • balance [gravity]
  • itching
  • pain 
  • sexuality
  • proprioception
( ) opposite. [] example
22
22
Note: This list originates from multiple sources —  Joseph Flanigan

The human senses belong in two categories.  1. The quantitative senses tend to have measurable physical characteristics.  2. The qualitative senses tend to have self-comparative characteristics.  Both quantitative and qualitative senses have at birth a natural response to recognize a change. A sense message signals the existing brain stasis model and triggers an action message about the change. The brain mixes many sense sources to build models. Rich models become stories. Some common language expressions, like a sense of well-being, can occur as a result of change provoked by one or more senses.

Life includes the intrinsic senses at birth or before..All senses have a precursor trigger. The trigger occurs as a stimulus from an event. The primary source for the event can be either internal or external to the body.  The intrinsic senses are internal events. Some senses are precursors for other senses. A fear threat response begins with an intrinsic proprioception event that triggers an emotional fear sense that initiates the response. The mind retains the model for every sense as a mood. A mood will contain one or more models for actions. 


Discussion:
These are learned models, not senses.
Þ            Dimensions – length, width, depth, time.
Þ            Birth – all senses exist, but some continue to grow.
Þ            Growth -  some senses
Þ            Reasoning – reading, calculations, planning, intuition, ESP are learned models.
Þ            Relationships – behavior, conduct, manners are learned models.
Þ            Sensations – the processing of senses, vertigo, posture, barning, position are learned modes. 
Þ            Awareness – shame, humility, remorse, guilt, honor, pleasure, happiness are social-emotional feelings.

Þ            Death – loss of all senses.


Other pseudo senses:
Time is a learned social understanding model of natural phenomena.
Behavior: A a complex model of time and a social sense merging into a new generated model.
Indifference
ESP
Intuition
Health

Undefined:
Quiescence > Interrupt > Chaos > Association > Order > Action

Psyc: Mood Change Process


Mood Change Process

The brain is always in a mood state. To read these words, the brain will invoke and revoke many moods. The term mood is very overloaded. 


Feature: Josephism

Josephism

This my list of Josephisms, most are mine, some are borrowed, some are quoted.
  • Live, Ride, Believe.
  • HERO means Help Everyone, Respect Others. 
  • Time, talent, treasure, and tenacity.  Tenacity – never give up.
  • Every step forward loses where it came from. 
  • Even to turn around and look behind is a different memory. 
  • Every step forward loses time. 
  • To turn around and look behind, loses time.
  • Every step forward is a new precious present. 
  • Our challenges grant us the gift of many precious presents.  So happy you are collecting them. 
  • Thinking creates thoughts for stories. 
  • You can only use one sense at a time.
  • My brain is the perfect chaos engine, happily enjoying every distraction. 
  • My writing is a scatter diagram of incomplete articles.
  • My brain is happy as a chaos generator.
  • Once I had a dollar. Once I wished for a dollar.  Once I earned a dollar.
  • Space and time are artworks of the mind. 
  • Ideas are always ideas.
  • A found penny is a treasure and a misfortune. 
  • Family first. 
  • A term is more than a language artifact, it is a stakeholder of ideas.
  • A term is the end of a thought and the beginning of communication.
  • Failing because of quitting is not the same as quitting because of failing
  • I am an individual. 
  • A horse my refuse water, my job is to provide the water.
  • No one gets an education. Education gets you.
  • To thrive is to change.
  • The future and the past are stories.
  • A life is many lives.
  • Devote time to the people you love.
  • Every intention is a precious present.
  • Thrive with determination.
  • The universe of men and the universe of women are two dimensions.
  • The mind’s eye sees its heart’s perspective.
  • Only we can determine our fatigue.
  • Three, one, two, one, three. 
  • WWJD - What would Joseph do?
  • Left, right, left; count, cadence count; 1 - 2 - 3 - 4; 1 - 2 - 3 - 4.
  • Peddling up-hill is life-affirming. Peddkng down-hill is fun.
  • A rock in the road is a signpost to a clear path.
  • Don't look at the pothole.
  • In every happy heart, there is love.
  • Love is a great spin that lasts forever.
  • Bikers ride in the sky because the sky starts at our tires on the road.
  • Remember to breathe from the gut.
  • The brain is a discrimination engine. The mind is a biased engine. 
  • I do not accept racism. 
  • The reason for war is economic power. 
  • Tomorrow you may wake up dead.  
  • Courage is only required for something you fear.
  • Bicycles are energy star rated.
  • Another name for the future is life.
  • Bicyclists always have the wind in their face.
  • I was disabled now I am adaptive.
  • In every happy heart, there are beats at for at least two people.
  • Real men have happy hearts.
  • To speak for itself, someone must hear it speak.
  • Here in the hell is the bathroom? I gotta piss.
  • First, learn 3 words, “I love you.” Then learn 2 words, “I surrender.” And one word, “OK”
  • Smile! Display your happy heart.
  • Biking, like wisdom, is applying the right leverage in the right place at the right time.
  • Sternum up, smile, see the world, shake it off, suck the gut, set intentions.
  • Strength, Agility, Flexibility, Endurance - SAFE conditioning
  • Fatigue equals vigor minus endurance.
  • What not is the truth. What is not is an opinion.
  • Ability-to-thrive equals quality-of-life and quantity-of-life.
  • We are eccentric beings in an eccentric universe.
  • The mind is a bucket full of moods.
  • To overcome one challenge challenges all challenges.
  • When walking, what foot moves first?
  • To see is the hardest part of the picture.
  • “Last one, best one.”
  • All exist in the Goodwill Grant.
  • Failure to thrive is not an option.
  • Truth enables space.
  • Honesty is the power of movement.
  • I refuse to be depressed. 
  • Respect permits identity.
  • Trust is the first principle of a relationship.
  • Love, faith, and hope bond family.
  • The trinity of fatigue: physical prowess, neurological coordination, cognitive planning.
  • A broken wooden stick has 3 parts, 2 pieces of wood and a break.
  • When filling up, make sure to clean the headlights.
  • 40 squats a day.
  • The mind trains the brain, the brain trains the body.
  • Behind the mind of a great engineer is a great artist.
  • Thanks for your service.
  • The word money means value, use, title. Payment is the transfer of title.
  • Fear threat reactions: fight, flight, freeze, fawn, fade, fold, forget.
  • The Apostle's Challenge: form, fit, function, finance, fabrication, family, fix, feature, fact, fear, fubar.
  • Wellness modifies yesterday, connected by empathy, grow with affinity, live through change, the journey for oneself, together experience life, remodel is an adventure.
  • A value is more than money:
    Abundance, Accountability, Achievement, Action, Adventure, Ambition, Awareness, Balance, Beauty, Being the Best, Calmness, Cheerfulness, Clarity, Comfort, Compassion, Competition, Connection, Contribution, Control, Courage, Creativity, Curiosity, Determination, Discipline, Effectiveness, Empathy, Energy, Enthusiasm, Excellence, Fairness, Faith, Fame, Family, Flexibility, Freedom, Friendship, Fulfillment, Fun, Harmony, Happiness, Health, Honesty, Honor, Humility, Independence, Integrity, Intelligence, Intimacy, Inspiration, Kindness, Knowledge, Liveliness, Love, Money, Nature, Passion, Peace, Perfection, Persistence, Philanthropy, Power, Respect, Security, Simplicity, Significance, Spirituality, Spontaneity, Strength, Stability, Success, Status, Teamwork, Tolerance, Tradition, Truth, Vitality, Volunteering, Wealth, Wisdom
Quotes I like

  • Our aspirations are our possibilities. - Samual Johnson
  • We will either find a way or make one. - Hannibal
  • Start by doing what is necessary, then do what's possible, and suddenly you are doing the impossible. - Saint Francis of Assisi
  • We stopped to smell the flowers, then went on our way,
  • They can because they think they can, - Virgil
  • Just trust yourself and you will know how to live.  - Goethe
  • One today is worth two tomorrows.  - Ben Franklin
  • It's wonderful what we can do if we are always doing. - George Washington
  • Faith in oneself is the best and safest course. - Michaelangelo
  • It is never too late to be what you might have been. - George Elliot
  • Clear your mind of cannot. - Samual Johnson
  • Only the heart knows how to find what is precious. - Dostoyevsky
  • Today I am out me-walking.
  • A journey of a thousand step must begin with a single step, - Lao-Tsu

Thursday, August 8, 2019

Veteran: Non-VA Emergency Care Claims Inappropriately Denied and Rejected

Response to the VA Inspector General Report of 8/6/2019

The VA Office of Inspector General on August 6, 2019, released a report "The VA Office of Inspector General on August 6, 2019, released a report "Non-VA Emergency Care Claims Inappropriately Denied and Rejected".  While thorough and the recommendations are valid, it's incomplete because the recommendations avoid fixing the main source of the problems. Claims Inappropriately Denied and Rejected".  While the recommendations are valid, it's incomplete because the recommendations avoid fixing the main source of the problems.



The report covers several topics related to VA operations, but it does not identify the specific source and cause that prompted the need for the report. The report recommends 11 corrective actions (below). None of the actions fix the source of the problems responsible for the business and financial disaster. When trauma occurs under adverse conditions,  and the veteran uses reasonable person judgment to obtain emergency medical treatment a non-VA facility, the Law instructs the VA to either pay-the-provider or reimburse-the-veteran for unpaid medical expenses.
The Law has statutes on eligibility and limitations.  This report is about one statute and the VA concocting a regulation the VA used to deny benefits. This concoction is a source of millions of dollars denying benefits to veterans.

The VA contrived a regulation not compliant with the Law -- it's a lie. The OIG report exposes the consequences of the lie.


Here is the regulation:



CFR 17.1005 (5) "VA will not reimburse a veteran under this section for any copayment, deductible, coinsurance, or similar payment that the veteran owes the third party or is obligated to pay under a health-plan contract.” The bayonet policy.



Here is the Law:



The Law's statute 38 USC 1725 (c) (4) (D) states “The Secretary may
not reimburse a veteran under this section 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."




What should have happened:



If the veteran is eligible and used a reasonable person's decision for adverse conditions had emergency room treatment at a non-VA facility, then the Law instructs the VA to pay-the-provider for the unpaid medical expenses. The Law instructs the provider to reconcile all other payments before invoicing the VA. VA Form 10-7078 is the invoice form providers submit that lists the unpaid medical expenses. Neither Title 38 nor Privacy Law grant the VA privilege to demand details of the provider's reconciliations. Once the VA establishes eligibility and adverse conditions with the veteran, the Law permits payment to the provider. The business process includes the execution of two contracts. The first, between the VA and the veteran, establishes rights to benefits. The second, between the VA and the provider, provides the benefit payout.



The statute means:



When the veteran’s insurance company pays a provider the insurance’s
share of copayment, the VA will not pay back a veteran for the money insurance
paid to a provider. That is all it means, that is all it can mean.  It is elegant.

1. The Law prevents a veteran from double-dipping on an insurance copayment.  The veteran cannot file for reimbursement using the insurance copay as the veteran's money. 

2. The Law does not include the term deductible. 

3. Without a reimbursement invoice, Form 10-7078, the rest of the statute is meaningless.

Explanation:



With any insurance, the insured contracts with an insurance company to reduce the insured payout on claims against the insured. When insurance pays out, the money belongs to the insured. Without the statute, the veteran can claim the insurance share of the copay is the veteran's money, and the veteran can invoice for reimbursement.  Statute, 38 USC 1725 (f)(3), is specific, third party (veteran, provider, insurance) means the insurance company and the veteran is responsible for the insurance contract. That responsibility means the veteran has title to the insurance payout.


The VA lie. The VA regulation twisted the statute to mean the insured copay and the provider as the 3rd party.  VA policy uses a self-centric relationship with other parties by claiming to be the 1st party (VA, vet, provider).  The Law clearly defines third-party as an insurance company. And the definition includes "A person or entity obligated to provide or to pay the expenses of, health services under a health-plan contract." The expense of insurance is the premium cost.  Payment of the premium establishes the insured, the veteran, has title to the money. The VA contrived the term expense to mean medical expense, which is a fee for a medical expense.



Title 38 USC 1725 includes other statutes the OIG report ignored. For an episode of care, a medical expense is a fee for a service. The VA fee payout is the maximum allowable amount (MAA). The VA uses the Medicare fee as the MAA and payment of the MAA exhausts other fees for the service.  The stack of papers in the OIG is because the VA does not have proper data systems to calculate a VA explanation of benefits.   The Law requires all payments be reconciled before invoicing the VA.  The invoice form does not include an entry for other payments. Without the data for the payments, the VA cannot determine the VA responsibility amount for the MAA. Consequently, staff intervenes on every claim. And the paperwork stack piles up.

The OIG report fixes nothing. It just creates more unnecessary procedures. Changing the regulation to be compliant with the Law will have an immediate self-correcting system-wide waterfall effect. The OIG report insists the recommendations use the same audit standards derived from a fanciful regulation. But the standards are wrong! An invalid standard makes the audit invalid.



OIG 11 Recommendations


For each recommendation is a jelly bean tag that exposes the nonsense in the recommendation. While the intent of the recommendation has some merit meant to improve business processes, the means test fails due to faults in the standards that contribute to the reason for a recommendation in the first place.



 1. The Under Secretary for Health reevaluates all claims denied after April 8, 2016, for the reason of “other health insurance” for appropriate corrective action. --- jelly beans*. What are there corrective actions, who writes this nonsense?  




2. Veterans Appeals Improvement and Modernization Act of 2017, Pub. L. No. 115-55. 22 Recommendations directed to the Under Secretary for Health were submitted to the Executive in Charge, who has the authority to perform the functions and duties of the Under Secretary for Health. --- jelly beans - nothing fixes the regulation.


3. The Under Secretary for Health develops and implements a control to ensure claims processors have the appropriate options in the claims-processing system of record to request evidence necessary to substantiate third-party liability claims. --- more jelly beans. Staff already has control procedures and they are stuck with jelly beans.


4. The Under Secretary for Health reevaluates all sample claims identified in this audit as inappropriately denied and rejected for appropriate corrective action. --- jelly beans staff uses the same reasons for denial the VA will not pay the copay per regulations.


5. The Under Secretary for Health reevaluates production targets, work production credits, and application of non-processing time for voucher examiners to ensure the production targets include claims research.  --- use good business practice even to make jelly beans? Sure redefine targets so the business can melt jelly beans.


6. The Under Secretary for Health requests and ensures the Office of Resolution Management conduct an organizational assessment of the Claims Adjudication and Reimbursement processing locations where staff reported they were directed or encouraged to improperly process claims and to take appropriate action. --- yahoo management can hawk jelly beans in a bigger bag.


7. The Under Secretary for Health implements strategic plans to ensure the Office of Community Care, Claims Adjudication and Reimbursement Directorate, emphasizes the accuracy of claims-processing decisions.  ---  the strategic plan is to invent more flavors for jelly beans. Reimbursement Directorate? The VA uses the term reimbursement as some type of spiritual gratuity. 


8. The Under Secretary for Health implements controls to ensure eligibility for overtime, telework, and annual performance bonuses for Claims Adjudication and Reimbursement staff includes all facets of performance  --- jelly bean manufactures know quality is the perceived use of labor, facilities, finance, and delivery. jelly beans have quality standards. Is the OIG telling the VA  management to implement quality controls?


9. The Under Secretary for Health develops and implements a clearly defined and effective quality assurance program that encompasses all claims decisions and includes a standardized process for supervisors to determine and effectively monitor the extent to which claims processors accurately rejected and denied non-VA emergency care claims. --- in jelly bean manufacturing production requires cost, schedule, and quality be balanced. Cost is the resource expense or man (labor), money, materials, and machines. Schedule means delivery of a quantity within a timeframe. Quality is the perception of the use of resources and of delivery fulfillment.  Quality assurance is a matrix management strategy. Before adding more staff, correct the tactical problems that caused the problems. The VA business is the distribution of money to pay a veteran's benefit. The information processing behind the distribution operation is a production business. The VA's quality assurance basis is compliance to the Law, not more staff.



10. The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities routinely communicate backlogs of incoming mail to Office of Community Care leaders with associated action plans to accurately record the date the documents were received---  So the OIG wants more VA staff? When the VA implements a business process, the result is more jelly beans.  


11. The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities and VA medical centers timely communicate claims decisions to veterans and providers to ensure veterans are notified of what VA needs to adjudicate the claims and what actions the veteran may take in response. --- the Law clearly states what information the VA needs to pay ER claims. The VA's business failure is not generating an Explanation of Benefits for every invoice. Privacy Law prohibits the VA from demanding details of a private contract between the patient, the provider and the patient's insurance company. This recommendation is so far off any business sense, it cannot receive a jelly bean.


If was a priest, I will tell the OIG to say three Hail Marys, a good Act of Contrition, and offer absolution after replacing jelly beans with right conduct. 



On page 11 is a footnote: 

18 Under 38 U.S.C. § 1728, VA acts as secondary payer when a third party is financially responsible for coverage of emergency treatment expenses received for service-connected conditions. Third-party means veteran, provider, other payers like private health insurance.


In some cases, under 38 U.S.C. § 1725, VA may, the Law says "shall be the secondary payer",  act as secondary payer,  when certain third-party liability exists for emergency treatment received for nonservice-connected conditions (e.g., situations involving auto insurance or workers’ compensation claims). For such instances, VA coverage is limited to the amount for which the veteran is personally liable after the amount of third-party coverage (e.g., exhausting coverage of automobile personal injury protection insurance coverage). The Bulletin, 3, no. 13 (June 26, 2014), states the rejection reason included “clarification of auto insurance vs. other 3rd party liability processes and requirements. It is imperative that sites utilize this rejection reason and forward the letter prior to denying a claim for third party liability.”



Follow-the-money:



Because the OIG does not understand the business transactions, the OIG cannot see the truth behind the problems the report identifies. 38 USC 1725 requires the  VA to either pay-the-provider or reimburse-the-veteran. In either case, contracts must exist to make payments.  Money transfers depend on at least five contracts, two government and three private: veteran & VA, VA & provider, and patient & provider, insured & insurer, provider & insurance. The contract between the VA and veteran are two separate agreements.  Title 38 defines the first agreement by granting benefits to the veteran, and the Congress assigns the VA as its agent to use the Federal Budget to pay for the benefits. This agreement is a pay-the-provider condition.



Reimburse-the-veteran is a separate agreement because the veteran pays the provider, and the VA pays back the veteran. Under pay-the-provider, the provider invoices the VA. Under reimburse-the-veteran, the veteran invoices the VA. Both agreements meet Congress's intended use of the money, but follow-the-money is different. The Law prohibits the veteran from invoicing the VA for the insurance's share of copayment. The Law instructs the provider to reconcile all payouts before invoicing the VA.



Warning. Because the veteran-patient does not have the Law instructing the provider to reconcile other payouts, the provider can invoice the patient for the full medical expense. As an ethical business practice, the provider will reconcile before invoicing the patient. If the provider has an in-network agreement with the insurance company, and the only payout is from the insurance company, the patient will be charged the unpaid medical expenses. Under pay-the-provider, the VHA limits the provider's medical expense payout to the MAA. Under reimburse-the-veteran Congress assigns the payout limit to the Secretary. DANGER. The MAA is lower than the provider can charge the patient, and if the Secretary chooses the payout limit for reimburse-the-veteran, the veteran will not recover the full amount paid to the provider.



Congress assigns the VA the responsibility for the veteran's share of the Federal budget, a follow-the-money analysis tracks the sequence of payouts.



Pay-the-provider Track Steps:

 1. veteran registers with VA

 2. insurance and provider determine in-network fees.

 3. insurance invoices insured

 4. insured pays the insurance premium

 5. provider invoices insurance

 6. insurance pays provider per explanation of benefits

 7. provider invoices VA

 8. VA determines the maximum allowable amount

 9. VA pays provider



Each step has multiple eligibilities, dependencies, constraints and other conditions that affect the flow of money. Each invoice is a request to transfer title to money. Each payment is a transfer of the title to the money.



The OIG reports details some of the VA's administrative problems during Step 8.



Step 8 not only determines the maximum allowable amount (MAA); it also exhausts further provider fees for the same service.



The Latrine detail:


For some reason the VA considers reimbursement to be some type of gratuitous spiritual act. Reimbursement is a business transaction. Rather than following a business process, the VA presupposes a condition, like the veteran, has private insurance and the VA has rights right to the terms of the private insurance, that the VA claims to be an immediate basis for the denial.



The latrine detail is a name for the VA bypassing the reimburse-the-veteran process. For some reason, the VA considers reimbursement to be some type of spiritual gratuitous act and grants themselves diety procedures including the purported right to demand information from the provider about private contract terms the provider has with other parties.



The OIG report reflects the consequences of not understanding reimbursement is a formal business process.



Reimburse-the-veteran steps:

 1. Steps 1-7 are the same as pay-the-provider.

 2. VA denies provider invoice

 3. Provider invoices patient per insurance EOB

 4. Patient pays provider

 5. Veteran invoices VA

 6. VA pays the veteran the maximum allowable amount.

 7. If the patient's insurance unpaid copay is greater than the MAA. the veteran cannot recover the out-of-pocket difference cost.





The difference between what the veteran paid the provider and what the VA will pay based the MAA is the latrine deposit.  In a data sample comparing an insurance copayment compared to Medicare fee for the same service, the VA would have paid several thousand less than the insurance copay. Plus, if the patient paid the patient copay, that is more money in the latrine.



Bad data, bad VA:



A critical document in the follow-the-money process is the data on the invoice the provider or veteran submits to the VA. The cost of an episode of care is a medical treatment that involves one or more medical expenses.  A medical expense is a fee for a service.



In order for the VA to calculate payout,  the VA needs:

 a. the fee for unpaid medical expenses

 b. the medical service code

 c. total of other payouts for the service



The current Form 10-7078 only includes the unpaid medical expense for the service. By Law, the provider must reconcile other payouts before invoicing the VA.

By Law, all payouts for the same medical expense reduce the MAA the VA can pay. The invoice form does not have a data entry that totals other payouts for the same service. Without the provider including the total, every invoice requires manual intervention.







Please fix it:



The OIG report's recommendations aid in grief experience relief.  Unless the OIG and the Secretary take action to close the wound that caused the trauma in the first place, the reconnections are like sand in an hourglass.



I. Correct the regulation

II. Recognize reimbursement is a formal business process.

III. Change the invoice form to include other payouts.

IV.  Respect private contracts

V. Honor the Goodwill Grant as private to the VA and not shared with others unless the use is for VA medical services.



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.




Author's Note:



I am not a lawyer, I am a good information analyst.  Everybody is an information modeler.  When a patient sees a doctor, the patient's normal information model experiences trauma. The doctor uses medical information models to create affinity information model about the trauma to create a diagnoses information model. 

An information analyst uses diagnostic and affinity tools to develop models for information science. When analyzing commercial business processes, contracts provide a formal definition of activity between two principals.  A principal can one and individual or group acting as an individual. A follow-the-money analysis tracks the title to money across contracts. An invoice is a demand to transfer title to money. A payment is a transfer of title to the money.

Title 38 Veterans' Benefits is a grant to a veteran for national service. The Federal Budget pays for government operations. Congress assigns the DVA to be Congress's agent to use the Federal Budget to pay for the veteran's benefits. Title 38 is a set of business rules Congress approved for the money's use. By following the business rules, the VA is a formal business activity. Behind 1725 is a least 5 contracts, VA & veteran, patient & provider, insured & insurer, provider & insurer, VA & provider where the title to money crosses. 

*jelly beans - the candy is firm and colorful on the outside, but soft and squishy on the inside.  In writing, a jelly bean is a comment about a statement that uses words that appear solid but lacks substance behind the words.



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