Sunday, August 4, 2019

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 GrantIf 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.

Friday, August 2, 2019

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.

Monday, July 1, 2019

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.

Thursday, June 27, 2019

Engineering: The Interloper Phenomena



The Interloper Phenomena

This is a computer folklore story I heard many years ago. The story illustrated the essence of technology security. I do not know how the actual story’s facts, however, the story can be told with different facts; however, the essence and outcome would be the same. 

In the mid-1970s, Wang was a company in Massachusetts who fostered a computer-based word processing system. Boston legal companies hired armies of legal secretaries. The secretaries would type pages and pages of legal documents flawlessly without errors. Most legal contracts required multiple original documents for signatures. The effort required to constantly key typewriters quickly and accurately could take years to be highly skilled. A typical large law firm could have dozens of legal secretaries. 

Wang’s marketing to the law firm was a simple business proposal. A Wang word processing system can replace many legal secretaries. The cost and the return made eliminating legal secretaries and easy business decision. 

From the legal secretary perspective, the word processor would destroy a craft that took years to perfect. Management offered training on the new system. The secretaries revolted and walked out of the offices. When the revolt quieted, the secretaries return to their offices. Upon entering the room, all the desks, and all the typewriters were gone. At the room’s center were a desk and a word processor. Management still offered training, but only a few secretaries would have a job.

This story is a framework for security schemes that repeats over and over. Security never has full immunity from agents of change. The design, development, and use of a security system establishes an entity with characteristics.  A security entity has two sides safety and risk. Within each side, the characteristics are the targets for the change agent. The phenomena caused by the change can be benign to malicious.    

An interloper is something or someone that interferes with a security system. The change agent is the interloper. The legal secretaries experienced the word processor as an interloper that intruded their hard-earned profession. A hacker is an interloper that breached the modern technology system. A mosquito biting the skin is an interloper. A bolt of lightning in a forest can be an interloper that causes a forest fire.

The term “interloper phenomena” refers to the action of the interloper and events regarding the interloper’s action.  A security consultant may recommend means to avoid an interloper phenomenon. A damage assessment team may resolve the effects of interloper phenomena.  The change caused by the word processor, the hacker, the mosquito, and the lighting are examples of the interloper phenomena.



Wednesday, June 26, 2019

Multiple Sclerosis: The Social Impact Matrix


MS: Social Impact

The Society Box

Inside the Box



Multiple Sclerosis: Trauma Evolution


MS's Trauma Evolution


The clinical diagnostic terms replace-remitting and progressive are eccentric progressions but with different impacts and consequences. Speach is an eccentric event. Every sound utterance is a different energy wave event. Every utterance heard filters into collective modals eventually to be words. Each ocean wave and wake is a unique eccentric event yet we recognize the rising and the falling.

MS is a multi-dimensional eccentric disease. Every event is a new event.

The experience dimensions from a trauma attack event are:

  • wound - the MS injury relapse and remission attack, broken connections
  • emotional - the psychological experiences
  • social - the change in relationships
  • disability - the connections remodeling 
The thrive dimensions consequences from the trauma event are:
  • Ability to thrive - the merge of resources enabling life to prosper
  • Quality of life - the perception of the value of resources
  • Quantity of life - the capacity of resources to sustain life
  • Will to thrive - the desire to thrive
Some of the life dimensions effects from the trauma event impact are:
  • denial
  • fear
  • grief
  • ability
  • proprioception
  • pain
  • money
  • family
  • work
  • insurance
  • therapy
  • training
  • medical
  • support
  • journey

Psyc: The Fatigue Elements


The Fatigue Elements



Psyc: Nervous System Communication Model


Communication Circuits

Psyc: Keep Your Grit



Psyc: Mood Change Process


Psyc: The 8 Fear Threat Reactions


Psyc: Maslow's Needs ...Joseph's Wants


Enjoy this Idea

A collection of Joseph Flanigan's drawings

  A collection of Joseph Flanigan's drawings.

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