January 6, 2016 7:22 pm Published by

As we express our gratitude, we must never forget that the highest appreciation is not to utter words, but to live by them

John Fitzgerald Kennedy
Just when you thought the Veterans Health Administration (VHA) could not worsen their current issues, there is a growing trend with the administration that is very disturbing. The VHA is trying to deny claims from emergency ambulance providers because of their failure to submit associated ER hospital bills along with their claims. This demand violates 38 CFR § 17.905 and 45 CFR 164.502(b), which restricts the administration from demanding frivolous information. This trend has a direct impact on our nation’s veterans.
Veterans deserve the very best from their country, which they risk their lives to serve. When the VHA denies claims submitted by providers, veteran patients are held liable as a result. This has many unfortunate and unwarranted consequences that veterans certainly do not deserve. Veteran medical liabilities contribute to the epidemic in veteran joblessness, bankruptcy and homelessness. The added stress leads to increased health problems, including Post-Traumatic Stress Disorder.
This catastrophe starts when veterans require emergency medical transportation. After the ambulance provider renders their service to the veterans, the provider bills their claim to the VHA. Consequently, the VHA then denies the claim for a failure to submit the associated ER hospital bill. The ambulance provider then resorts to billing the veteran for the uncompensated care.
When the veteran cannot afford to reimburse the ambulance provider, their credit scores may suffer. In today’s society, credit scores are critical to job seekers. A damaged credit score makes it difficult for the veteran to find work, which may force the veteran into bankruptcy. The force of bankruptcy often drives veterans into the cold and dark streets.
Veteran homelessness is a large issue among the veteran community. According to the National Alliance to End Homelessness and the Homeless Research Institute, “causes of homelessness among Veterans are similar to causes of homelessness among non-Veterans (interrelated economic and personal factors and shortage of affordable housing). Nearly half a million Veterans pay more than half their income for rent. More than half of them have incomes below the federal poverty level.” “In 2010, the Department of Veteran Affairs (VA) estimated that on any given night there were 76,000 homeless veterans sleeping on American streets.” Further, a 2013 study by the University of Southhampton shows that people who are in debt are three times more likely to have a mental health problem that those not in debt. The study also concludes that people in debt are more likely to suffer from depression, drug dependence, and psychosis and the results also indicate that those who die by suicide are more likely to be in debt. All these mental health problems prevent people including veterans from progressing out of homelessness. VA uncompensated care only aggravates this issue. Veterans cannot afford to carry the financial burden and responsibility of the Veteran’s Health Administration.
Veterans are not the only ones affected by this trend. The emergency safety net that protects our veterans becomes compromised. Each time the VHA wrongfully denies an ambulance provider claim, they jeopardize the provider’s financial stability by compromising their ability to preserve their solvency. In turn, their ability to provide veterans with medically appropriate health care is compromised because the ability to practice medicine is the direct result of cash flow. Without a solution, lives are in danger because if more ambulance crews disband, others must pick up the slack, and wait times go up. In an emergency situation, no soldier should be left behind.
Providers exist to provide services to veterans. The VHA is wrongfully creating tension between veterans and providers every time the VHA denies a provider claim.
Denying an ambulance provider claim based on failing to submit the associated ER facility bill creates several important issues and problems that are outlined below:
According to 38 CFR §17.905:
“Copies of medical records generated outside VA that relate to activities for which VA is asked to provide payment or that VA determines are necessary to adjudicate claims under §§ 17.900 through 17.905 must be provided to VA at no cost.”
Evidence of a case study, which is explained below, demonstrates that the VA is manipulating this law to require ambulance providers to submit the associated ER facility bill as part of their medical records. Then, they deny their claim in its entirety if the ambulance provider does not comply.Ambulance Providers maintain their own records of the transport that include medical records from their encounter with the veteran. This is the scope of their “medical records.” The associated ER facility bill of the veteran is irrelevant in determining reimbursement of an emergency medical transport and does not relate to the emergency transport of the veteran. The associated ER facility bill relates to the activities performed at the medical facility and are only relevant in claims the medical facility submits, not the ambulance provider. Not only does this follow from the above statute, but it is logical. Unfortunately, it seems logic evades the VHA at times.
Perhaps the most alarming aspect of this issue is the consequences of the Ambulance provider actually requesting, receiving, and submitting the associated ER facility bill to the VHA. 45 CFR § 164.502(b) is a long standing HIPAA rule that protects the use and disclosure of veteran’s health information and states:
(b) Standard: Minimum necessary – Minimum necessary applies when using or disclosing protected health information or when requesting protected health information from another covered entity or business associate, a covered entity or business associate must make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.
Hospital records contain protected health information of the veteran. The VHA does not need this information to investigate and adjudicate an emergency ambulance transport claim. As mentioned above, the ambulance provider maintains their own record. The VHA is not making any reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose which is to adjudicate an ambulatory claim.
In the case study below, you will see that the VHA is denying the ambulance provider’s claim in its entirety unless the ambulance provider wrongfully submits the associated ER facility bill.
In essence, the VHA is telling the ambulance provider that if you don’t violate this law, we are not going to pay you. This may sound similiar to the crime of coercion.
III. Case Study: Multiple claims submitted to the VHA and denied for requested associated ER records.
On November 11, 2015, our office submitted Notice of Disagreements for our ambulance provider’s claims that have been denied for requesting the associated ER facility bill. Each and every claim submitted to the VHA contesting this denial type was overturned and immediately reimbursed by the VHA with no questions asked.
In each claim that was submitted to the VHA and denied, the ambulance provider was forced to send the outstanding balance of their service to the veteran in an attempt at reimbursement. Through our effective enforcement and advocacy strategies and efforts, not only did we succeed in overturning the provider’s claim, but we also succeeded at removing burdensome financial liability from our nation’s soldiers, totaling thousands of dollars.
Moreover, our office submitted a FOIA request in regards to any legal authority or guidance that the VHA relies on when denying a claim for an associated hospital record. According to this FOIA request, the VHA relies on 38 CFR §17.1003(a) and 38 CFR §1725. These two regulations are silent as to anything related to the VHA having the right to deny a claim based on not receiving or permitting the VHA to request the associated hospital record from the ambulance provider. The VHA’s response indicates that they do not have any kind of support to require the ambulance provider to submit the associated hospital record.
The VHA should be fully aware with the problems related to requesting an ambulance provider to submit an associated hospital record. As discussed above this is a serious violation of the veteran’s HIPAA rights.
It is clear that the VHA continues to develop tactics and strategies to reimburse as little as possible or avoid reimbursement all together. They count on the lack of resources and time of providers and veterans to manipulate the laws and regulations they are governed by to avoid reimbursing providers who provide medically appropriate healthcare to our country’s veterans and veterans who cannot afford the high cost of health care.
The effect of this was surely magnified this holiday season when many veterans who require medical care cannot afford the treatments and transport. With more people on the road and the epidemic of veteran homelessness on the rise, higher incidence of emergency medical situations create a larger demand for ambulances. It is paramount that we work in concert to fight and challenge the VHA in every claim that is submitted, contested, denied, or challenged by their allegations. We must:

  • Ensure the VHA is following the laws and regulations they are subject to and governed by.
  • Challenge the VHA’s denials for all associated hospital record requests.
  • Maintain aggressive follow up to prevent the VHA from ignoring emergency provider claims and ensuring proper claims adjudication to preserve veteran appeal and representation rights.

In the end, this is about the veteran’s ability to access medically appropriate health care. The purpose and duty of the VHA is to provide financial support for veteran’s who require medical care. Part of that duty is to ensure federal funds intended for the veteran are released timely and responsibly.
If you are a non-VA ambulance provider who has provided care to Veterans of the United States Armed Forces that have had claims denied for an associated hospital record, we want to hear from you. Report your unfair payment practice of the VHA below.
If you are a veteran experiencing financial hardship because of uncompensated medical bills, we want to hear from you.

Please contact:
ERN/ The Reimbursement Advocacy Firm
Brian Ford, J.D., CCA & Writer
(714) 995-6900 ext. 6920

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This post was written by ernncra