Veteran: Comment on the Wolfe vs VA case

Comment on the Wolfe versus VA case

Wolfe & Boerschinger v. Wilkie, No.18-6091(DATED: September 9, 2019 PER CURIAM); 38 C.F.R. § 17.1005(a)(5) is invalid because it is contrary to 38 U.S.C. §1725; reimbursement of emergency medical care at non-VA facilities

References below.

The Court's opinion and the process leave me with big questions and that the VA can be ordered in a direction that will fix the problem.

The Court and NVLSP have the entire basis for the case wrong. The estimated cost does appear more sensational than factual. Unless the basis changes the DVA will not change its business rules. 

The Law says:

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."

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. The wording is exact. 

Without the statue, the veteran can claim the money from insurance belongs to veteran and invoice for reimbursement.   The statute prohibits double-dipping where insurance and the VA pay for the same medical expense. The VA does not have a regulation to prevent double-dipping.

The VA created 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 statute is correct, the regulation is fictitious.  The VA abuses the term reimbursement to include payment to the provider. 

Furthermore, the VA inappropriately uses the regulation to demand an explanation of benefits confidential business information from the patient and the provider. The Law defines third party to be the insurance company (patient, provider, insurer).  The VA switched the third party to mean (VA, veteran, provider).

The correct wording for CFR 17.1005 (5) is “The VA will not reimburse the veteran for a copay or coinsurance money paid under a health plan contractor.” ( A health plan contract can payout to either the medical services provider or to the insured.)  Or better: CFR 17.1005 (5) should be “The VA will not reimburse the veteran for an episode of care payments made to the provider or the veteran for episode’s medical expenses. “

Unless the regulation is like the above, the veteran can double-dip on payments made to the provider by asking to be reimbursed for payments made directly to the provider. In the case of medical insurance copayments, the title for the money belongs to the veteran patient. Medical insurance payment is exactly the same as if the veteran patient wrote at check to the provider.

Copay and coinsurance are terms specific to pay for a medical expense where the insurer pays some and the insured pays some. The definition of a medical expense is a fee for a medical service. 

The VA has no legal right to demand an episode of care explanation of benefits from the provider, the insurance company, or the patient. The patient, insurance, and provider have a private contract. By demanding the EOB and refusing to pay benefit is bureaucratic extortion. The Law requires the provider to reconcile all payout before invoicing the VA. That is all the information the VA needs.

The VA’s limit on medical expense payout is the maximum allowable amount (MAA) which is the same as the Medicare fee. Once the MAA is paid by any party, the Law exhausts further charges for the medical expense. I suspect the large cost estimate is calculated for the unpaid insurance payout rather than the MAA. 

If the VA suspects the provider being dishonest about reconciling payouts, the provider commits fraud in which case the problem belongs to legal and not a reason to deny veteran’s benefits.

The Court and the DVA treat reimbursement as a gratuitous act and not a formal business process. 38 USC 1725 instructs the VA to either pay the provider or reimburse the veteran. This statute defines the existence of 3 contracts and to make a payment the contracts require an invoice and a payment. Contracts: 

• Veteran & VA, 
• VA and Provider, 
• Veteran & Provider. 

Elsewhere in 1725, 2 other contracts exist. 

• Provider and The Veteran Patient, 
• Veteran Patient (insured) & The Patient Medical Insurance company (insurer)
• Note: no contract exists between the VA and the insurance company. A reimbursement requires an invoice before payment.  Unless the veteran files a Form 10-7078 (or equal)   invoice, the VA cannot make rules that bypass the Form.

Statute 38 USC 1725 (c) (4) (D) states “The Secretary may not reimburse …” Without a reimbursement invoice, the rest of the statue is void.  The VA regulation completely ignores the Law's reimbursement requirement.

Contract law and privacy law supersede Title 38.

To help understand Title 38, these are some of the first principles:

• Title 38 is Congress’s life grant of benefits to all veterans for the veteran’s national service.
• The Department of Veteran Affairs is Congress’s agent to pay veteran’s benefit expenses from the Federal Budget.
• Title 38 defines the veteran’s benefits and the business rules the DVA uses for operation and payout.
• A veteran’s benefit is a fee for a Title 38 service.
• By Congress’s grant, the veteran owns the benefit, the DHA has the responsibility to provide services and payout from the Budget.
• The DVA is not a veteran. The DVA is an agent of Congress, and cannot own benefits.
• The veteran owns all benefits.
• To receive Federal Budget benefits, the veteran must register with the DVA.
• The DVA likes to market itself as a benefits organization. While pleasant-sounding, the words misspeak its authority and responsibility.
•  Section 38 USC 1725 The Law instructs the Secretary to either pay-the-provider or reimburse-the-veteran.
• Pay-the-provider and reimburse-the-veteran is a formal business process of invoice and payment.
• Contract law and privacy law are the frameworks of business rules.

If NVLSP represented me with the Court of Veteran's Appeals, this is a list of conduct I would not expect the attorney to allow. 

• NVLSP allowed the VA to use the terms copayment, coinsurance, and deductibles in defense arguments.  These terms copay and coinsurance mean two payers, the insurer copay and the insured copay.  The VA created a regulation for the insured copay; however, the Law applies only to insurer copay.   The term deductible is not in 38 USC 1725.   If the DVA does follow the Court, the veteran can double-dip on other payments made directly to the provider. It is simple, the medical insurance payout is the property of the insured. When insurance pays a provider, the insurer acts as a broker for the insured to pay the bill for the insured.
• NVLSP allowed the VA to use the explanation of benefits (EOB) information to deny the veteran benefits. In a community provider episode of care, the EOB is private information, and the VA has no legal right or authority to demand.
• NVLSP allowed the VA to claim itself as the first party in separate contracts. The Law defines the veteran as the first party.
• NVLSP allowed the VA to substitute medical expense (fees for a medical service)  for insurance expense (cost of insurance)
• NVLP allowed the VA to limit the meaning of copay and coinsurance to mean the patient's share rather than the insurer's share.
• The CAVA, NVLSP,  and the VA tend to use the term reimbursement as a gratuitous act and not as a formal business process.

References:

United States Court of Appeals for Veterans Claims Docket Case Number:18-6091

Case NO. 18-6091 AMANDA JANE WOLFE AND PETER E. BOERSCHINGER, PETITIONERS, 

Contonx: Contonix Exertion Scales

The Contonix Exertion Scales is a self-assessment grading method on the effectiveness of Mind-It Training (MIT) exercises. Tone is an active event that occurs when forces act together to maintain balance. If a person extends an arm and holds is stead, all biological systems act together to hold tone. As soon as the moves, the biological systems continue to act together to sustain continue change in tone. The means to change from one tone state to another is connection toning.

Multiple Sclerosis: The cause of my MS.

Could something from 1971 point to reason I have multiple sclerosis?

When I was a teenager, my father earned extra money by doing did odd jobs for realtors like constructions, painting, cleanup. From the time I was 8 and until I was 18 and enlisted in the Marine Corps, I would go to many jobs with him. I think he had is own right of passage rules, because starting high school, he assigned me the high jobs like roof repair. I had no fear of heights. My enlisted ended in 1971, I  was 21 and often I would help him.  From an incident 50 years ago, my mind is still clear about what happened on a 1971 summer day.

Dad asked me to carry a bundle of shingles up to the roof where others worked. Putting the shingles on my shoulder, up the ladder, and walking across the roof, I put the shingles down for the roofers. I turned around to start down the roof, my legs froze. I could not move. Dad was calling me to come down for another bundle. I could barely hear him. He must have sensed something was wrong. He called out to one of the roofers to check on me. I am still standing frozen. The roofer looked at me, waved for my Dad to come up. The other roofer came oven and the three of them helped me to sit on the roof.  Dad told the roofers to help him get me down. They sat me on the roof. By pushing and tugging they slid me down to the ladder and help me turn over. One on the ladder, Dad is talking me down and help put my feet on the rungs while the roofers held my hands,  At halfway down, I could hold onto the ladder legs. And a few more rungs I was down.  Sill a little wobbly, Dad help me to lean on the pick-up.

A few minutes passed I was fine and could do other work. The building only was just a one-story house. During those few minutes, I was frozen with fear. Before the incidence, I had no fear of heights nor standing on the edge. The crew and I  had a good laugh about being me being afraid of work.  I never worked on a roof again. Forty-five years later, the exact same thing happened. I was at the gym, exercising on a spin bike. I felt fine, not physically exhausted. But, when I stood up, my legs froze, they would not move, I could not tell them to move. Standing there for a few minutes, the stiffness passed.  The legs became wobbly, and I was able to move to the next machine.

For 45years, the incidence on the roof caused self embarrassment. I did not understand. I always felt I let my Dad down. I showed weakness on the job but also the image of a Marine being afraid of a little old roof. I knew I was not a coward, I just did not understand what actually happened. Twenty years after the roof incident, I was diagnosed with multiple sclerosis. When the incident happened in the gym, I knew exactly what happened. Both the roof and the gym incidences was an MS exacerbation. In my life with MS, I spend a lot of time studying MS from the inside-out. systems perspective, not from the biological science perspective. The incident in the gym was a breakthrough event in my studies about MS and fatigue. For movement, we need three resources. The physical prowess to move. The neurological coordination of body systems. And, the cognitive capability to plan movement with the ability to send coordination orders for the plan.

The incident on the roof and in the gym was MS neurological fatigue. Both incidents had exactly the same pattern, frozen legs.  fear of being a lost and defenseless, and rest relaxing the frozen legs. If my analysis is true, then in the twenty years, before the MS diagnosis, from the time I was 21 until 40,  I experience undiagnosed  MS symptoms.  In 1976, I was a field engineering for a medical instruments company and my service territory was the central western states and the land area was a third of the United States.  The work involved fixing equipment in hospital labs and at university reseach labs. Travel to the cities meant flying. In a week's time could be one to four flights a day. In and out of Denver, to Salt Lake, to Phoenix to Albuquerque and back to Denver was an easy week.  Once I was so fatigued, I had to spend several days in a Salt Lake hotel room just resting.  I remember tossing the keys to the valet, bearly being able to walk to the front desk. I had to sit in the lobby and rest before going to my room. I thought I had the flu, but now I know the symptoms were from an MS attack.  When I returned to Denver, the family doctor gave me some vitamin shots along with bed rest. I was 25. A few months later the fatigue happened on the last flight home to Denver.  Will power got me to the parking lot and my car. For two days only I walked between the bedroom and the bathroom.  One the third day, I went to the family doctor again. More vitamin shots and rest.  At 26 I was burned out and 4 days later I quit that job.

The story just sounds like being overworked. The fatigue was MS.   At the time,  the fatigue appeared as job stress. The one thing I recall was not walking well and the legs being wobbly. Years later, I learned that wobbly walking is a symptom of MS. 

Could something have happened to me between 18 and 21 that caused MS? I am the only MSer in generations of past and present family members. I have an idea about what happened to me that is exclusive of others. I am still working on the idea.

Once I identified the fatigue pattern, I could recall other fatigue events before and after diagnosis with the same pattern. I named the pattern the -n event for the no-neurological coordination. Each fatigue event is different,  only a few are  -n severe disabling events. 

Psyc: Fear Threat Reactions

Fear Threat Reactions

When faced with a perceived threat, humans and animals exhibit a range of fear-threat reactions. These reactions are physiological and behavioral responses that help individuals cope with the perceived danger and protect themselves from harm. The most well-known fear threat reactions are the "fight-or-flight" responses, but there are other adaptations that organisms may employ in the face of fear.

Fight-or-flight response

The fight-or-flight response is a common physiological and behavioral reaction to perceived threats. This response is mediated by the sympathetic nervous system, which triggers a cascade of physiological changes that prepare the body for action. These changes include:

• Increased heart rate and blood pressure: This provides the body with the necessary oxygen and nutrients to fight or flee.

• Muscle tension: This allows for rapid movement and defense.

• Dilated pupils: This enhances vision in low-light conditions, which may be necessary for escape or defense.

• Release of hormones: Hormones such as adrenaline and cortisol prepare the body for action and increase alertness.

The fight-or-flight response is characterized by two primary behavioral options:

• Fight: This involves confronting the threat directly, either verbally or physically.

• Flight: This involves fleeing from the threat to a safe location.

The choice of whether to fight or flight depends on various factors, such as the perceived severity of the threat, the individual's assessment of their own capabilities, and the availability of escape routes.

Reaction	Description
Fawn	Hide - make oneself invisible, the threat still exists.
Fight	Attack - self-defense by disarming the threat
Flight	Run - move away as fast as possible.
Freeze	Stop - cannot move, moving an make the threat worse
Finesse	Wade - Facing the threat and preserve anyhow.
Forget	Ignore - The cause for fear is not a threat.
Fold	Surrender - Give up, accept the fact the threat is beyond one's control.
Fade	Backup - Disassociated from the threat.

Neurological Reactions

The neurological reactions, also known as the "four Fs," involve specific neurological pathways and activations. These reactions are:

1. Fawn: The fawn response is associated with the activation of the parasympathetic nervous system, which promotes relaxation and conservation of energy. This response is mediated by the release of neurotransmitters such as gamma-aminobutyric acid (GABA) and acetylcholine.

2. Fight: The fight response is mediated by the sympathetic nervous system, which triggers a surge of hormones such as adrenaline and cortisol. These hormones prepare the body for physical action by increasing heart rate, blood pressure, and muscle tension.

3. Flight: The flight response, like the fight response, is mediated by the sympathetic nervous system. Adrenaline and cortisol play a key role in this response, preparing the body for rapid movement and escape.

4. Freeze: The freeze response is associated with the activation of the dorsal vagal complex, a part of the nervous system that regulates freeze behavior. This response is mediated by the release of neuropeptides such as opioid peptides, which promote stillness and reduce pain perception.

Neurocognitive Reactions

The neurocognitive reactions, also known as the "four Fs," involve cognitive processes and emotional regulation mechanisms. These reactions are:

1. Fade: The fade response involves suppressing or diminishing the emotional intensity of the fear response. This is achieved through cognitive reappraisal, which involves changing the way one interprets the threatening situation.

2. Fold: The fold response involves avoiding or withdrawing from the perceived threat. This may involve physical avoidance or mental disengagement from the situation.

3. Forget: The forget response involves suppressing or erasing memories of the fear-inducing event. This is thought to be mediated by the hippocampus, a brain region involved in memory formation and consolidation.

4. Finesse: The finesse response involves managing or controlling the expression of fear, often through coping strategies such as deep breathing or relaxation techniques. This response is mediated by the prefrontal cortex, a brain region involved in executive function and decision-making.

Phases of a Fear Threat Reaction

The four shock phases of a fear threat reaction are:

1. Trigger: This is the initial phase, where the individual perceives a threat and the fear response is activated.

2. Action: This is the phase where the individual reacts to the threat through either neurological or neurocognitive reactions.

3. Recovery: This is the aware phase, where the individual's physiological and emotional state returns to baseline.

4. Reaction: This is the safety phase, where the individual makes cognitive plans to change risks associated with the trigger.

The body's means to execute these reactions involve a complex interplay of hormonal, neurotransmitter, and cognitive processes. These mechanisms allow individuals to cope with perceived threats and protect themselves from harm.

While the threat reaction has a physical-behavioral transition response, the transition seems seamless in life practice.

Contonx: Four Square Fitness

Four Square Fitness

 

S.A.F.E Conditioning

              S - Strength
              A - Agility
              F - Flexibility
              E - Endurance

In the Art of Contonx, strength, agility, flexibility, and endurance are the finite elements of tone. Everything in the body's anatomy elements moves, cells, organs, fluids, nerves, bones, muscles, etc. A SAFE condition defines the relationship between the elements.

Pysc: Did Adam Have a Bellybutton?

Did Adam Have a Bellybutton?

“Did Adam have a belly button?”, the Question is a philosophical question related to a bible story. The Question proposes a polar answer of either a yes or a no. The Question itself makes the suppositions that the character Adam exists, that something exists called a belly-button and that Adam may have the procession of the belly-button. 

The Question defines the affirmative to be "Adam has a belly-button", then negative to be "Adam did not have a belly-button.  A "no response" cannot be either yes or no,  but yes response means a proof argument. The negative response is an absence of proof, the response is a negative answer.

The Question suggests the scope of understanding is context similar to both the proposer and the proposed.  Although the answers may include valid responses where the proposer and the proposed to have different or distinct context.

If the proposer and the proposed have a mutual context with similar exposure to bible stories,  the Question's proposition is a philosophical interrogation related to creation and God. Four options provide the bases for opinions.

1. Creationist -- No. God created Adam, therefore no need for a bellybutton.
2. Evolutionist -- Yes. Homo sapiens evolved as a biological natural occurrence.
3. Interventionist -- Yes. Some eternal force triggered evolutionary species to gain abstract rational thought. The bible story suggests God choose the homo sapien Adam to have free will. Perhaps some other unknown source of external force triggered or deposited a person with advanced brain capability.
4. Exclusionist - No. Knows about the story but discards it and considers the story fiction.

However, if the proposer and the proposed have no mutual context, the Question is about a person named Adam and his bellybutton.   The Question does suggest other responses that are not yes or no.

1. Inquisitive - Why is Adam's belly button important?

2. Rationalist - What is the reason for the question?

3. Knowlege - No concept of creation.

4. Indifferent - I don't care.

5. Unknown - Not discovered.

6. Not important - No. important and unimportant are still important. Not important means no existence to make important.

7. Alternative - A different story about creation.

The world is full of different tribes and cultures. Each may have similar ideas about creation or the lack of ideas itself.  A rock has a complete response.