Veteran: Behind the Mission Act is a lie.

Behind the Mission Act and non-VA provider care is a regulation lie regarding payout at a non-VA facility. for emergency treatment.

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 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 a lie. A follow-the-money analysis reveals the truth. 

With any insurance, the insured contracts with 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.  The statute 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 payout.

The 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 defines third-party as an insurance company. The third-party 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. 

Title38 grants benefits to veterans and charge the VA as an agent of Congress to use the Federal Budget to pay the costs for the benefit.  The veteran owns the benefit and in relations with VA the veteran is always the 1st party.  Also, reimbursement requires an invoice, the submitter is the 1st party.  The VA can only be the 2nd party which disconnects the VA from other patient private contracts.

Basically, the statute prohibits double-dipping by the veteran claiming that any insurance payout is the veteran's money. The veteran cannot file for reimbursement using the insurance copay as the veteran's money.  

38 USC 1725 first statement is for the VA to either pay-the-provider or reimburse-the-veteran. If the veteran does not invoice for reimbursement, the rest of the statue cannot apply.  The VA regulation contrived a business condition that cannot occur for either pay-the-provider or reimburse-the-veteran. If for some reason the Veteran did pay the provider, the most the VA will payback is the maximum allowable amount (MAA) which is the same as the Medicare fee.

The current regulations state that a veteran, under adverse conditions and eligibility requirements, has emergency care treatment at a non-VA facility has two possibilities for payment of the medical expense. If the veteran has no private insurance, the VA pays the maximum allowable amount. If the veteran has private insurance and the insurance deductible is not met or the medical expense has a patient copay, the VA claims that by law the VA cannot pay the copay or deductible.

Title 38 uses the term deductible only when the VA uses private insurance for cost recovery. The regulation contrived a false fact about the law.

The regulation did not change with the Mission Act.

The VA demands the insurance’s explanation of benefit from the provider or the VA will not pay. This is extortion. The relationship between the patient, provider and insurance company is a private contract.  The law does require the provider to reconcile other payouts before invoicing the VA. The Law does not grant the VA authority to demand private information.

When the veteran has authorized medical treatment at a non-VA provider, the provider is an agent of the VA. As an agent, the VA's payout follows 38 USC 1729 for private insurance at a VA facility.  The VA has no provision that defines non-VA ER providers to be an agent. When the veteran follows VA protocols and has ER treatment, that episode of care should be an expressed agency and 1729 payout applies not 1725. However, 1725 does apply as the definition for the agency. 

From a business analysis perspective, Title 38 is a set of business rules that assign the VA to be Congress’s agent to use money from the Federal Budget to pay the costs of the benefits. As a business necessity, the VA requires veterans to register with the VA to receive the payout which includes service and distributions. The veteran is a client of the VA, not a member.

Headline: Title 38 grants lifetime medical treatment for all veterans. The grant provides an out of pocket limitations on medical expenses.  A medical expense is a medical service for a fee. The limitation is the maximum allowable amount (MAA) and the same as the Medicare fee. Payment of the MAA exhausts other fees for the same service. If the veteran registers with the VA, the VA pays the MAA. If a veteran does not register with the most any provider can charge is the MAA.  If the veteran pays the MAA, the payment exhausts other fees service in an episode of care service the same as if the VA paid.

The Goodwill Grant: If a veteran has a private health plan contract for medical insurance, the Goodwill Grant is the veteran's volunteered permission of the veteran's private health insurance for VA's direct cost recovery at VA facilities. 38 U.S. Code § 1729 - Recovery by the United States of the cost of certain care and services.

The Grant only applies to VA facilities. Because permission to use the Grant is voluntary, permission to use the Grant can be withdrawn at any time for any cause.  The veteran can withdraw the Grant for the non-VA facility episode of care, the VA cannot use the Grant information with the provider. From the VA perspective, the veteran would not have private insurance. The regulation cannot apply.

Title 38 as a set of business rules allows a follow-the-money analysis. Contract law and primary law supersede the title  and under 1725 the business requires at least 5 contracts

• VA & veteran, 
• provider & VA, 
• patient & provider, 
• patient & insurance, 
• insurance & provider. 

When the episode of care is at a non-VA facility, the VA does not have a contract with private insurance. A simple contract is between two principals. A third-party may affect the transaction between the principals, but the third-party is not a contract principal.

The Law does not give the VA legal permission to demand a third-party explanation of benefits. VA Form 10-7078 requires medical expense information. By Law, the provider or the veteran, in the case of reimbursement, must reconcile other payouts before invoicing the VA.

The MAA bureaucratic negligence is the VA not providing the provider or the veteran an explanation of benefits as soon as the provider submits the invoice. Instead, the VA uses the Goodwill Grant to determine the status of the private insurance payouts. If the insurance deductible is not meet or the policy has copays, the VA because of the regulation, immediately denies payment to the provider. Without the EOB neither the provider nor the veteran can establish financial obligations.

VA Form 10-7078 does not include a data field for the money total the provider receives from other payees.  The data is legally necessary to calculate the MAA. By Law, if the amount paid by other payees (POP) exceed the MAA, the veteran owes nothing, and the VA has no payout. Because the form does not include POP data, the VA breaks privacy laws by demanding the insurance EOB.

Fix the form, fix the MAA standing.

Remember regulations are not the Law.  

I am bewildered to not find a challenge on CFR 17.1005 (5) based on simple English alone not to be compliant with the Law.  Without a reimbursement invoice, the rest of the statute is meaningless. 

Notes: 

38 CFR § 17.1005 - Payment limitations.

Veteran: The VA ER regulation at a Non-VA hospital is not legal.

Veterans Administration Breaking the Law

Bureaucratic Negligence:

The Veterans’ Health Administration denies benefits for veterans who, under adverse conditions, receive emergency room treatment at a non-VA facility, usually a community hospital. If the veteran has no private insurance, the VA pays the maximum allowable amount for the medical expenses. If the veteran has private insurance, the VA denies payment of the private insurance deductible and copay.

VA Policy:
There are limitations on VA’s ability to provide coverage when a Veteran has other health insurance (OHI). If OHI does not fully cover the costs of treatment, VA can pay certain costs for which the Veteran is personally liable. By law, VA cannot pay:
• Copayments
• Coinsurance
• Deductibles 
• Similar payments a Veteran may owe to the provider as required by their OHI

VA is also legally prohibited from providing coverage for individuals covered under a health-plan contract because of a failure by the Veteran or the provider to comply with the provisions of that health-plan contract, e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment

This is the Federal 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.

This is the statue from Title 38:
38 USC 1725 (c) (4) (D) 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.
T
he policy and the regulation do not conform to the Law. Under some wishful notion, the VA contrived the regulation. The Law is complete and accurate. False facts clues:

The Law is specific the veteran must request reimbursement. Elsewhere in the Law, statue instructs the VA to either pay-the-provider or reimburse-the-veteran.

The Law uses the predicate "may not" Regulations changed the predicate to "will not" which removes executive discretion. 

The Law does not contain the term deductible.

Copay is a binary payout; the insurance owes some, and the patient owes some.

All payout from insurance is owned by the insured. The insured may instruct the insurance to pay the provider. The money from insurance is the insured’s money.

The Law defines third-part to be the insurance company. In the regulations, the VA changed third-party to be the provider.

The veteran is responsible for the insurance premiums that establish rights to the payout.

38 USC 1725 (c) (4) (D) prevents the veteran from double-dipping on reimbursement by identifying the insurance payout is the veteran’s money. The payout is the patient's money.

The Law requires all providers to reconcile payout from other payees before invoicing the VA. When the VA pays, the payment exhausts other fees for the service. When the VA dismisses medical expenses that may be accounted as deductibles, the VA fails to determine the maximum allowable amount (MAA) for the entire episode of care's medical expenses. 

The medical fee exhaust amount is calculated by subtracting the MAA from the total of other payouts. By law, the VA must determine the exhaust value.

 The Law means:
The VA will not pay the veteran for any insurance copays paid by the veteran's private insurance. 

That's all it means. That’s all it can mean. Everything else in the regulation and policy is an invention.

Somebody in the VA does not know a medical expense is a fee for a medical service; an insurance expense is the cost of insurance.  "owes the third party or for which the veteran is responsible under a health-plan contract." means the premiums paid to the insurance for the cost of the policy. Paying the premium means the insured owns the payout.

Cost: This contrived regulation cost veteran and providers millions of dollars. Providers turn the bill over to collections.

Privacy Law:
The VA demands the provider submit the private health insurance explanation of benefit before the VA will pay. The contract between the patient, the provider and the insurance company is a private contract. The Law does not grant the VA authority to demand the terms from a private contract. Providers who submit EOB to the VA can be sued by the patient.

Veteran: Why do soldiers obey orders

Do soldiers obey orders because they must or because they want to? 

One of the earliest expression of rational thought begins when the person is a child. If ever seen a child refuse to eat, that refusal is rational thought.  An adult may not consider the child's choice as rational, but from the child's perspective, the child uses free will to choose. Usually, something occurs to change need and the child will want to eat. The need/want paradigm is built into the mind and its the same for all people of all ages. Life skill changes the paradigm by the accumulation of permission-constraint conditions reflected as behavior. By necessity, military training implants the permission-constraint conditions into specific choices for must-do-will-do behavior.  While leadership determines the needs of the command, the want-to follows orders is the soldier's will-do choice.

Grip expressions like, "If I must, I will do it if I have to." are concessions for want-to.

A soldier who wants-to disobey a lawful order is packed with a soldier's permission/constraint choices. Social resolution may belong to the court.

Veteran: VHA and Emergency Treatment at a non-VA facility.

Business Rules Analysis

of the VA and Constitutional Law

The Veteran's Administration denied at veteran the medical expenses for a veteran's visit to a non-VA facility emergency room. The medical reason for the visit is not relevant except to know the visit occurred as an adverse condition and the VA accepted the visit as a ligament cause.  Even though the veteran is eligible for ER treatment, the veteran may not receive benefits to pay the hospital bill.

The VA's interpretation of the law separates eligibility from the actual distribution of benefits. In other words, being eligible for benefits is not a guarantee of benefits. The word benefits is an overloaded term that has a slightly different meaning in different contexts. The rules that govern VA benefits start with Constitutional Law. The VA administration interprets the law to create Department regulations used to conduct the business operations defined by the law. Within the Department are many business operational levels, for each level the regulations require more context-specific guidelines. For each operation to operate as required by the law, the VA interprets regulations into policies. Then for the business execution of operations, the policy becomes procedures. The business implementation for the VA begins with the law, then interpretations for regulations, then the policy, the procedures. If the three levels of interpretation are accurate, a procedure must be a substantiated as a valid interpretation of the law. None of the VA documents are the Law. The VHA has created regulations that the VHA claims to be "the Law" but in fact, the documents are not the law.

The VA's use of the term benefits is confusing. However, there is a business model that is the same model as VA benefits. The Department of Veteran Affairs is one of the President's fifteen Executive Agencies. As an executive department, every agency has an account report. Standard accounting practices use journals listing entries as a named item or service with the associated cost. A journal entry is a fee for an item or service. This pairing, service, and fees, is the same pairing the VA calls benefits. An accounting journal classifies the journal entry as a valid financial report category. All classification systems impose eligibility restrictions separating items that belong to a category from those items that cannot belong in the category. The business model for an accounting item is eligible(item and cost). The VA model for benefits is the same eligible(service and fee) where service and fee are named a benefit. The VA may acknowledge a veteran is eligible for a service but procedures qualify fee allowance. The separation of services and fees by procedure control over fees complicates veteran's medical expense coverage.

The VA sent a denial that said "by law" the VA cannot pay the ER copay medical expense. Rather than accepting the denial as fact, I wanted to know what was the actual wording in the law. My understanding that by being eligible for VA benefits, the medical treatment would be covered by the VA. We did not know that the VA, before the fact, misrepresents itself about ER benefits. When the VA sends a denial, the veteran can appeal the decision. To make an appeal, the veteran must show a reason to reverse the denial. To find the appeal reason meant finding the exact part of the law the VA used a reason for the denial. As an Americal citizen for 70 years, I am embarrassed that I did not know how Constitutional Law is part of our government.

The VA has helped me and others. Sometimes a situation happens that is in conflict with a reasonable person's thinking. In the case of payouts for ER treatment at a non-VA facility, the VA created regulations not substantiated by Law.

38 USC Veteran's Benefits Chapter 38 USC 1725 Reimbursement for emergency treatment is a good business rule with one major exception, the two-year requirement for (B) the veteran received care under this chapter within the 24-month period preceding the furnishing of such emergency treatment.

The real problem with 38 USC 1725 is the VA contrived regulations not substantiated in the Law. Under the Law, the VA either pays the provider or reimburses the veteran. All generally accepted business practices require an invoice from the provider. While the Law does not use the term invoice, the Law does define payouts. In a follow the money analysis, the invoice is a benchmark document. The VA can accept invoices from either the provider or the veteran. The Law defines payout to the veteran as reimbursement. In VA regulations the VA incorrectly uses the word reimbursement to mean direct pay the provider. The word reimbursement means "to pay back.”  Black's Law dictionary further explains "It means to make return or restoration of an equivalent for something paid, expended, or lost; to indemnify or make whole." The Law is clear either pay the provider or reimburse the veteran. In order for the veteran to invoice for reimbursement, the veteran must first pay the provider.

The VHA has denied many many veterans with the statement "VA has no legal authority pay to a veteran’s cost shares, deductible, or copayment associated with OHI" This statement is complete bullshit. The Law states "The Secretary may not reimburse a veteran under this section, Limitations on Reimbursement, for any copayment or similar payment that the veteran owes the third party or for which the veteran is responsible under a health-plan contract." The statement prohibits the veteran from double dipping by claiming the veteran's OHI payment as a pre-paid amount by the veteran. The veteran is responsible for the health plan contract. If the health plan contract does pay some of the medical expense, the Law does not allow the veteran to include that payment for reimbursement.

Somehow, some way, somebody at the VA twisted the use of copay to mean the veteran's payout responsibility.  Copay and coinsurance mean two payer's, the insurance and the patient. The veteran's unpaid medical expense is still the responsibility of the VHA.

The Law makes it impossible for the veteran to prepay the provider. Under the Law, "establish the maximum amount payable under subsection"  sometimes called maximum allowed amount (MAA). The VHA does not provide an explanation of benefits that explains the MAA.

If the MAA is the same as the Medicare fee for a medical service, the veteran could overpay the provider. If the veteran pays the provider a fee higher than the MAA, the VA cannot by Law reimburse the overpaid amount. The VA regulations for ER treatment at a non-VA facility for MAA, EOB, and reimbursement is bullshit.

I have not seen an animal shit on top of shit. I have seen different dung piles. The VHA in its regulations for non-VA facility ER care has managed to pile shit on top of shit.

If the VA pays the provider the MAA, the payment exhausts further provider fees for the same medical service. As a veteran the most out-of-pocket expense a veteran should ever pay the provider is the MAA. Without a VHA EOB, neither the provider nor the veteran can determine the correct invoice or payout. The absence of a VHA EOB is the stinkweed in the bullshit.

Perhaps the worse pile of bullshit is the VHA breach of its judiciary trust on the Goodwill Grant. If a veteran has a private health plan contract for medical insurance, The Goodwill Grant is the veteran's volunteered permission of the veteran's private health insurance for VA's direct cost recovery at VA facilities. 38 U.S. Code § 1729 - Recovery by the United States of the cost of certain care and services. The Goodwill Grant does not give the VHA permission to use the terms of private insurance with other providers. Because the Goodwill Grant has terms for copay and deductibles, the VHA uses its knowledge of the terms to demand the provide insurance EOB from the provider. This demand is bureautic extortion refusing to pay without an EOB. The provider has the legal responsibility to reconcile other party payouts before invoicing the VA.

In the case of non-VA facility ER treatment, the VHA has no legal authority to demand an EOB from the provider. The provider, the patient, and the insurance company have a private contract. The VHA cannot demand information about the private contract.  If the veteran invoices for reimbursement, the veteran is responsible for the reciliation of the other payer payout. The VHA has no legal authority to demand the EOB from the veteran. If the VHA suspects the veteran or the provider submit fraudulent invoices, the VHA has the responsibility to report to the legal authority.