Veteran: First Principles of Veteran Benefits

Veteran: First Principles of Veteran Benefits

Anytime an area of interest transforms into another area of interest, the process of transformation requires three steps. The first step is accepting the original area of interest, the last step is generating the intended area of interest. In between are the transformation rules. The rules act as a catalyst where the meaning of the original can become intended. The process of information transformation happens everywhere.

As you read these words, the eyes scan the symbols and transform the words into thought. In between are the multiple transforms where each transformation rules contribute to the eventual intended area of interest. In arithmetic, the predicates, add, subtract, equal are the rules for transforming numerical values. First-principles is another name for the intermediate rules. Each principle is a valid test for both the original and the intended area of interest.   

For veterans' benefits, the Law is the original area of interest with the statutes contained in US Code Title 38, Veterans' Benefits.  In most cases, the intended area of interest is the Title 38 Code of Federal Regulations Veterans' Benefit used to define the business practices of the  Department of Veteran Affairs (VA).  Title 38 also establishes the United States Court of Appeals for Veterans Claims (CAVC) with statues from 38 U.S.C.  7251–7299. The Department of Veteran Affairs operates as an Executive Department of the United States President.  The Court of Appeals for Veterans Claims operates as a Federal Court, not as part of the VA.

The CAVC charter is Title 38 Statues. The Count has intermediate rules that are the principle to transform the Statues into the Count's judicial practices. The VA creates the regulations without intermediate rules where the regulation is in the VA's business interest  Therefore, the regulation may not be in the veteran's interest.  

The First Principles (or Rules)

This is my proposed list of the missing first principles. The list begins with the missing definition for Title 38.  

1. Title 38 USC Veterans' Benefits is Congress's lifetime wellness grant of benefits to each honorably discharged veteran for the veteran's national service with the Department of Defense. 
2. Title 38 statutes define the grant's services.
3. Congress allocates funds from the Federal Budget to pay the fees for the services.
4. A veteran's benefit is the paid fee for a Title 38 service.
5. By Law, the veteran owns all benefits.
6. The DVA and the Court of Appeals for Veterans Claims are Title 38 services.
7. Veteran disability compensation is a Title 38 service.
8. The DVA is an agent of Congress to administer the Budget's allocation and to provide Title 38 services.
9. Title 38 is a set of business rules for Title 38 payouts.
10. Once a veteran always a veteran.
11. To receive Title 38 services, the veteran must register as a client with DVA.
12. The DVA is not a veteran, therefore the DVA cannot own benefits. 
13. The DVA is an agency, not a club, veterans are clients, not members.
14. In all agreements between the veteran and the DVA, the veteran is always the first party principal. 
15. For veteran's medical treatments at a community provider, the DVA establishes an expressed agency with the provider thereby the medical expense is the same as if the treatment occurred at a DVA facility. 
16. A medical expense is a fee for medical service.
17. A treatment for an episode-of-care may include one or more medical expenses. Medical trauma may include one or more episodes-of-care. 
18. The purpose of insurance is to reduce the insured liability. The payout from the insurer is the insured's property.
19. An insurance company may act as the insured's agent to make claim payments. The payment is exactly the same as if the insured paid the claim.
20. The Goodwill Grant is the veteran's volunteered permission given to the DVA to used the veteran's private insurance for cost recovery at a DVA faculty. The grant permits the DVA to be a principal to make cost recovery claims with the insurer. 
21. The DVA has a fiduciary trust responsibility to use the Goodwill Grant's private information only within the DVA and not with any DVA's agents. 
22. The DVA may assist Congress in determining a veteran's eligibility for a particular service, once eligible, the DVA cannot deny the service as a veteran's benefit.
23. All veterans at the time of active duty discharge are eligible for Title 38 benefits and may register with the DVA for Title 38 services.
24. The DVA cannot deny an honorably discharged as a client.
25. The veteran has the responsibility to use Title 38 services for the veteran's wellness.      

The First Test of a Regulation

For a regulation to be valid, the regulation must pass the Title's wellness test (Rule 1).

Does the regulation provide for the wellness of the veteran?

If the regulation does not pass the test, the regulation fails the purpose of Title 38 and therefore the regulation does is not comply with the Law. While the DVA is a business operation, the DVA must conduct its operations as an agent of Congress. Rule 1 states the purpose of Title 38 is to provide services for veteran's wellness. Rule 1 applies to the DVA. 


                                    

Veteran: Veterans Day Speech at Loveland High

Veterans Day Speech at Loveland High

Corporal Joseph Flanigan

Marine Corps

January 1968-January 1971

San Diego, California

Veteran’s Day Speech, November 11, 2014.

In 1967, when I graduated high school, I wanted to be a nuclear physicist. I just thought it would be amazing to study the insides of atoms. Well, it was Vietnam time, and the draft enlisted youth to the military as soldiers. In college, I soon realized I needed more money for tuition, and I volunteered for the draft to get 3 years of college for 2 years of service using veteran’s benefits. While in boot camp, I learned the first of many Marine ideals, like, “Once a Marine, always a Marine.”

On November 10, 1775, the Second Continental Congress passed a resolution staring the Marine Corps. From that date, every Marine is trained in combat to defend our United States. As I was to learn, for every Marine on the front line, there are many jobs Marines do to support missions. 

Yesterday was our 239^th birthday. 

While in boot camp, you hear the drill instructors shouting. “In my Marine Corps, we do 100 push-ups before chow!” “In my Marine Corps, we don’t walk, we run!” “In my Marine Corps, we crawl on our belly to rest!” And you think to yourself, this guy is insane, always saying “In my Marine Corps” before every challenge and command.

While in bootcamp, you take lots of tests that will determine your job in the service. My results came. “Private Flanigan, you have been selected for a new job. Something called computers. I didn’t know anything about it. You don’t have to take the job. If you don’t, you will be shipping out for Vietnam.” At 18, I just made of the smartest life decisions, “Sir, I accept.” That decision began my 45-year career in computer science.

Boot camp graduation, the drill instructor hand you the Maine Corps Eagle, Anchor, Globe emblem, shakes your hand and says “Welcome to my Marine Corps” And then you understand.

For the next year, I went to a special Marine Corps school, completing 4 years of college courses in 48 weeks. I still remember the first day of class, and the first words of the instructor, “How high can you count on your fingers?” By then, I already knew in the Marine Corps, the easy answer was always wrong. After instructed listened a few wrong answers, he announced: “In this class, you will learn to count.” I learned to count, many did not.

We were to training on Tactical Data Systems. This was the first generation of computer-assisted flight and ground weapons. From the ground system, officer flight controllers commanded combat missions on military targets using data from radar, missiles, aircraft, and other armaments. Even though I was trained at the highest level, I was a Marine and could be transferred with the systems into combat. The Marine Corps changed my dream of looking into the physics of atoms to using atoms of electricity.

My duty was in Garden Grove, California,  testing and preparing new systems for deployment. We worked long hours in 6 foot cubes chasing computer circuits. To change a programs in second generation computers, technicians rewired circuits. 

Occasionally we would be assigned special duty. Marines who died in Vietnam would return to the states at the El Toro Marine Airbase. Today, I can still see the coffins being unloaded from giant cargo planes. Standing in company formation, stone silent, we watched, and said silent prayers.

When a Marine leaves active duty, we honor each other, no longer officers or private, just Marine. In greeting other Marines, we say, our motto, “Semper Fi”, forever faithful.

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, 

Veteran: 38.1725 ~ Information Model

Veterans' Benefit 38 USC 1725  Statues as an Information Model

38 USC 1725 is the Law about 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 to 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 includes seven information attributes: name, title, asset, amount, use, event, warrant. Each attribute has one or more definite values. 
• name - a label to identify money conveyance
• title - the money's owner
• asset - the title's social collateral 
• amount - an asset's quantitive or qualitative measure
• use - purpose or encumbrance for conveyance
• event - the conveyance instance 
• warrant - title's ownership right and sustainability.
• value - data about the attribute
  
  
• 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 Asset Ownership  ~ copyright, trademark, procession
• Follow-the-Money Þ Process Þ Trade Þ Money (conveyance)
• 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 an 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:

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

• 15 executive departments (includes VA and DOD)
• 41 commissions (includes National Council on Disability) or the 
• 66 independent agencies (includes NASA),. 
• 10 official agencies (includes Smithsonian Institution)

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.

Veteran: Non-VA Emergency Care Claims Inappropriately Denied and Rejected or General, Do You Know the Definition of a Veteran's Benefit?

Response to the VA Inspector General Report of 8/6/2019 --General, Do You Know the Definition of a Veteran's Benefit?

Update February 2020
Original August 2019

General do you know the definition of a veteran's benefit. Don't be embarrassed, nobody in the DVA doses either. There are volumes and volumes of examples but no definition. At the end of this post is the correct definition. 

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. Sir, you should be embarrassed.

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.

The poor staffers who wrote the report do not understand  Title 38 principles and principals.  The illustration Congress & Veterans & DVA & Provider is a mind map of the principles in 38 USC 1725 and their relationships. The report failed to determine first-order problems. The child says, mom where are the potatoes? The mom says there are not potatoes, the grocer did not have any. The grocer says, there are no potatoes, my distributor did not have any. The distributor says, there are no potatoes. The farmer did not have any. The farmer says there are no potatoes because it did not rain.

The farmer not having potatoes is the first-order problem. Not raining is a different problem. The distributer is second order, the grocer is third order, the mom is fourth-order, the child is the problem reason. The report fails both to identify the reason and the first-order problem.

The section name for 38 U.S. Code 1725 is "Reimbursement for emergency treatment." I am bewildered that DVA regulations and rules authors did not read the first two statutes. A section name is a language convenience to represent a collection of statues on a particular topic.  The section name is not a statue nor does it represent a constraint applied to the statues.

The term reimbursement is a well-defined business process. The Law says:
(a)General Authority.—
(1)Subject to subsections (c) and (d), the Secretary shall reimburse a veteran described in subsection (b) for the reasonable value of emergency treatment furnished the veteran in a non-Department facility.

(2)In any case in which reimbursement is authorized under subsection (a)(1), the Secretary, in the Secretary’s discretion, may, in lieu of reimbursing the veteran, make payment of the reasonable value of the furnished emergency treatment directly—

(A)to a hospital or other health care provider that furnished the treatment; or

(B)to the person or organization that paid for such treatment on behalf of the veteran.

The Law is very clear either reimburse-the-veteran or pay-the-provider.  In both cases, an invoice must come from the veteran or from the provider. By Law,  the DVA  cannot reimburse the provider.

The Law statue "organization that paid for such treatment on behalf of the veteran" gives the veteran permission to submit a reimbursement invoice for the veteran's private health plan payment to the provider. 38 USC 1725 (c) (4) (D) prohibits the veteran from double-dipping on the medical expense payout, payment from private insurance and payment from the DVA.  The regulation CFR 17.1005 (5) permits double-dipping.

Without reason or cause, the DVA created a regulation completely disjoint from the Law.  And in doing so, DVA cost the wellness of thousands of veterans and perhaps even deaths.

A Fictitious 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.” A bayonet policy, stabbing veterans in the back by denying the Goodwill Grant.

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 grants 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 a third-party as an insurance company. Note: third-party is a statue defined term, the words cannot be interpreted as a contract principal relationship with the DVA. By term's definition, the veteran must the first principal and the community provider must be the second principal. And the statute defines who the third parties can be.  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.

Big Note: The payout from a veteran's private health care plan is the property of the veteran. The veteran is the policyholder, the insured. A company may assist with the plan's premiums and broker policy terms, but the policy and the payout belong to the insured. If the insurer makes copayments to a provider, the insurer acts at the insured agent for the payment. As the insured's agent, the insurance payment is the property of the insured and the payment is the same as if the insured wrote a check to the provider.

Bureaucratic Racketing

The regulation says:

CFR § 17.1002 ...will be made only if all of the following conditions are met:

(d) At the time the emergency treatment was furnished, the veteran was enrolled in the VA health care system and had received medical services under the authority of 38 U.S.C. chapter 17 within the 24-month period preceding the furnishing of such emergency treatment;

The Law says:

USC(2) 1725(b)Eligibility.—

(1)A veteran referred to in subsection (a)(1) is an individual who is an active Department health-care participant who is personally liable for emergency <tr><td><span style="vertical-align: inherit;"><span style="vertical-align: inherit;">Patient &amp; ProviderC</span></span></td><td>Patient</td><td>Provider</td><td>Other Provider</td></tr>treatment furnished the veteran in a non-Department facility.

(2)A veteran is an active Department health-care participant if—
(A)the veteran is enrolled in the health care system established under section 1705(a) of this title; and

(B)the veteran received care under this chapter within the 24-month period preceding the furnishing of such emergency treatment.

DVA's translation of the Law into regulations has two motives, permission or denial. The DVA has business controls payout of the Federal Budget. The DAV's business motive is to limit the payout, therefore regulations tend to establish rules that deny a payout.

This statute should not be in the Title. Somebody from the DVA must have lobbied Congress to have it become Law. Because the episode of care is emergency treatment, the two-year requirement has no medical motive. As a business requirement, the statute and the regulation is bureaucratic racketing. Neither makes business sense, the DVA does not spend the budget for healthy veterans. 

A Law may be interpreted in one of two ways, graning permission or preventing permission. The DVA as a business makes rules to limit payout; therefore, the DVA's perspective will use regulations to deny the veteran's benefit payout for services.

A reason for this statute and regulation is for some self-fulfilling leverage to justify active DVA client count. No medical reason exists.

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 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 I was a priest, I would 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 a 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 a 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

Attention to orders Inspector General: Any time the term money occurs inspect its use for title, value, use, and asset. Make a mental note of this example: I {title} have $10 {$ dollars asset} 10 {value} in the bank {use}. And if you can think just a little more, an invoice is a demand for money's title to pay for goods or services. Payment is the transfer of title to invoicer. Follow-the-money means to follow the title. Value, asset, and use are audit conditions.

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. The VA considers reimbursement to be a 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.

Maximum Allowable Amount Calculation

The Law  details the DVA's payout for ER treatment: 

38 USC 1725 IS A(c)Limitations on Reimbursement.—

(1)The Secretary, in accordance with regulations prescribed by the Secretary, shall—

(A)establish the maximum amount payable under subsection (a);

(B)delineate the circumstances under which such payments may be made, to include such requirements on requesting reimbursement as the Secretary shall establish; and

(C)provide that in no event may a payment under that subsection include any amount for which the veteran is not personally liable.

 (c) (3)Payment by the Secretary under this section on behalf of a veteran to a provider of emergency treatment shall, unless rejected and refunded by the provider within 30 days of receipt, extinguish any liability on the part of the veteran for that treatment. Neither the absence of a contract or agreement between the Secretary and the provider nor any provision of a contract, agreement, or assignment to the contrary shall operate to modify, limit, or negate the requirement in the preceding sentence.

" in accordance with regulations prescribed by the Secretary" mean A, B. C applies.

"establish the maximum amount payable" uses payment amount based on the Medicare medical expense. If Medicare does not have a service code, the VA defines its own. A maximum allowable amount (MAA) is an invoice amount and it also means the maximum payable amount (MPA) payment.  If the VHA published an explanation-of-benefits, like HCP publishes, the calculation is:

 
MAA - other payment = MPA where MPA  "extinguish any liability on the part of the veteran for that treatment."  The Law does not use the term MPA, but invoice and payment are business transaction terms related to money. An invoice is a demand for a title for some dollar amount. Payment is the money transfer of the title for the invoice amount.

The Law states the most the government can pay for the veteran's medical expense is the MAA. The medical needs event determines the business rules for a patient's medical costs. The event creates a medical services episode-of-care wherein care requires one or more treatments wherein a treatment requires one or more medical services. Each cost for a service the medical expense. The definition of a medical expense is the fee for the service. For billing purposes, each medical expense has a Current Procedural Terminology (CPT) code. The American Medical Association determines the code for each medical expense. However, the code itself does not state a cost. Medicare does state the MAA and the MAA equals the MPA. The Law limits veteran medical expense cost to the Medicare MAA. 

The CPT lists thousands of medical services, but not all. And, the provider's medical tend to be more than the Medicare MAA. The  

Even the IRS, 26 USC 213 puts rules on medical care.

1. Case: where other payments is more than the MAA
     If MAA - other payments less than or equal zero, then MPA is zero. 

2. Case: where the veteran has no HCP or other payment,s are s zero: 
     If MAA - other payments equal MAA  MP then MPA = MAA.

3. Case: where other payments pay some to the MAA.
    If MAA - other payments less than MAA then MPA = MAA - other payments.

In all three cases per 1725(c)(3), the VA's payment exhausts other charges by the provider.

In order for the VA to calculate the MPA, the VA needs the amount other payments contributed to the MAA. The current VHA rules instruct  VHA staff to demand the patient's private property of the HPC explanation-of-benefits. That demand is illegal.

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

General,  you should go kick some ass. Since 1968 when the Corps started my career in the computers until today, the VA has the single biggest data blunder in my 50 years of experience. All the jelly beans in your report did not identify the VA's failure to follow the law with third party payment.

I am going to give you a million-dollar consulting fee for FREE. Change the provider's invoice form to include a single data field. accumulated payments. With that single value, the jelly beans turn to water. Yep, the field is not in medicare codes. The DVA and Medicare do not use the same payout rules.

Get some of those IT staff busy doing software for indirect cost recovery and for an automated explanation of benefits and a little artificial intelligence for veteran eligibility, so the DVA  can clean its mess. The DVA reports direct cost recovery as revenue but does not report indirect cost recovery.

The first job is to publish the electronic data format for the new field, provider IT will be happy to update their side. The books will balance faster.

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.

General, here is a crazy simple fix. 

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.

General, The DVA Has No First Principles.

Everywhere we go and everything we do, we process translations. Right now you are translating these symbols into thoughts. To calculate 1 + 1 = 3, you learn the + and = are the first principles of arithmetic. First-principles are everywhere except at the DVA.  When the DVA translatesTitle 38 statutes into regulations, the DVA has no first-principles. 

Rather than trying to explain, I am just going to give you 25 first principles. Think of each principle as a correctness filter between the Law and the regulation. You know the expression, it goes in one ear and out the other. First-principles provide a listening gate. 

This is a list of first principles. The list begins with the missing definition for Title 38. 

• Title 38 USC Veterans' Benefits is Congress's lifetime wellness grant of benefits to each honorably discharged veteran for the veteran's national service with the Department of Defense.
• Title 38 statutes define the grant's services.
• Congress allocates funds from the Federal Budget to pay the fees for the services.
• A veteran's benefit is the paid fee for a Title 38 service.
• By Law, the veteran owns all benefits.
• The DVA and the Broad of Veteran Appeals are Title 38 services
• Veteran disability compensation is a Title 38 service.
• The DVA is an agent of Congress to administer the Budget's allocation and to provide Title 38 services.
• Title 38 is a set of business rules for Title 38 payouts.
• Once a veteran always a veteran.
• To receive Title 38 services, the veteran must register as a client with DVA.
• The DVA is not a veteran, therefore the DVA cannot own benefits.
• The DVA is an agency, not a club, veterans are clients, not members.
• In all agreements between the veteran and the DVA, the veteran is always the first party principal.
• For veteran's medical treatments at a community provider, the DVA establishes an expressed agency with the provider thereby the medical expense is the same as if the treatment occurred at a DVA facility.
• A medical expense is a fee for medical service.
• Treatment for an episode of care may include one or more medical expenses. Medical trauma may include one or more episodes of care.
• The purpose of insurance is to reduce the insured liability. The payout from the insurer is the insured's property.
• An insurance company may act the insured's agent to make a claim payments. The payment is exactly the same as if the insured paid the claim.
• The Goodwill Grant is the veteran's volunteered permission given to the DVA to used the veteran's private insurance for cost recovery at a DVA faculty. The grant permits the DVA to be a principal to make cost recovery claims with the insurer.
• The DVA has a fiduciary trust responsibility to use the Goodwill Grant's private information only within the DVA and not with any DVA's agents.
• The DVA may assist Congress in determining a veteran's eligibility for a particular service, once eligible, the DVA cannot deny the service as a veteran's benefit.
• All veterans at the time of active duty discharge are eligible for Title 38 benefits and may register with the DVA for Title 38 services.
• The DVA cannot deny an honorably discharged as a client.
• The veteran has the responsibility to use Title 38 services for the veteran's wellness.

The Business of Title 38 Benefits

The definition of a veteran's benefits is the paid fee for a Title 38 service. Congress's allocation from the Federal Budget pays the benefit fee. For any money transfers, contacts between principals include invoices and payments.

For a community care emergency treatment episode-of-care, behind 38 USC 1725 are many contracts.

Principals: veteran, DVA, provider, patient, HPC, other payers, other providers

• For community care, DVA is disjoint from the patient's HPC.
• *For VHA in-facility, the Goodwill Grant limits veteran's HCP as a 3rd Party for VHA cost recovery. The veteran's HCP is the veteran's agent for making payments to VHA.

The DVA's only business legal right to other payouts to the provider to the total amount others paid the provider for the episode-of-care medical expenses.

HIPPA is for medical information not for business reporting. DVA as the veteran's medical provider has access to HIPPA.

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 an affinity information model about the trauma to create a diagnosis 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. 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.