non VA emergency care in Tricare, VA, ChampVA, Fee Basis, Medicare etc. Forum

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non VA emergency care

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phantomfixer1		#21	[url]	[-]
Posts: 1094 Dec 22 10 9:57 AM	VABA wrote: Sorry to make light of a horrific situation. I'm serious. If you really believe your gall bladder is going to burst, or if you're in severe pain (more severe than yesterday) then you ought to call 911 and let them decide what to do with you. Don't be shy. If they want to take you to the nearest ER, go for it. If you're still reading this, you probably want more details:. I could never second-guess what your VA is going to say or do, so I'll just spell out exactly what I know for sure applies in this situation. A P&T vet having an ACUTE gall bladder attack needs to call 911 and go to whichever ER they take you. If anyone at Fee Basis were ever to deny a P&T vet's bills when the vet believes he's having an emergency, I'd fight it publicly, and win. But I think you're concerned because your pain has lasted for weeks, and so is not acute. If I were you, I'd weigh these options. a) Call 911. When they put you into their wagon, that is evidence that a medical professional has determined that you need to go to an ER. They will, by law, take you to the nearest facility that is most appropriate for your condition. Tell everyone you're a vet and tell them to bill the VAMC in OKC. Next day, call the VA and tell them where you are, why, and how you got there. (P&T vet with Tricare/Medicare A only/No insurance/MC A&B takes ambulance to Valley View Hospital for Abdominal Pain.) If you're admitted inpatient, tell the social worker/discharge planner on your ward to coordinate with the VA Care Management Team within 48 hours to see if VA wants to transfer you or not. Then relax and let them do their jobs. OR b) Walk in to the nearest VA clinic first thing in the morning and don't leave without being seen by a VA doctor. If the doc thinks you're having an emergency, they'll call an ambulance for you. Don't offer to drive to save a few bucks--when the VA calls the ambulance to their clinic, that's called a CLINIC REFERRAL, and it is always paid for without question. If you can't get past the nurse, ask to see the Team Leader. Then call the Chief of Staff, Mark Huycke, MD at (405) 456-3306 or the Associate Director Anne Kreutzer, at (405) 456-3303. OR c) Call the OKC VAMC at 405-456-1000 now and ask the telecare nurse to leave an urgent message for your doctor. Then call back at 0800 and get the first available appointment with any doctor at all. Good luck. thank you very much....good useful info.
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Starliteman	Non V.A. Emergency Care	#22	[url]	[-]
Posts: 63 Dec 22 10 10:39 PM	Hey guys, just wanted to jump in here because I have had experience of the necessity to go to the local E.R. The ambulance picked me up at home transported me to nearest E.R. My heart rate was going ballistic, my life was in danger, and I was treated. My wife called the V.A. from that E.R. and advised them the situation. The E.R. Doc called lifelite and I was transported to a specialty heart hospital for further treatment. Agian the V.A. was called and advised where I was and my current situation. All the nurse said to my wife is O.K. To make a very long story short, the V.A. refused to pay the bill and I am stuck with $56000.00 judgement. I have appealed to BVA for payment but that will take a long while. There was no excuse for the V.A. to refuse payment I had documentation that all of this was emergent. The fee basis in Flowwod , Ms responded that they deemed this non-emergent over ruling the cardiologist evaluation and statement that all the care I recieved was Emergent.... So beware going into a non-va E.R. No matter what the regs say, you might end up like me. It seems the fee basis people can do what ever they want about payment and you have no recourse. I was at 50% rate at the time. Starliteman
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Bob.brownwaternavya...	more on this	#23	[url]	[-]
Posts: 140 Dec 27 10 2:12 PM	http://www.nonvacare.va.gov/
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Stash42	Medical care while traveling	#24	[url]	[-]
Posts: 3 Jan 10 11 1:34 PM	VABA wrote: Stash42, when you're traveling away from your home VA's service area, you can access VA healthcare, and you can even have Fee Based Purchased Care in up to three different VA jurisdictions. This is useful for long-haul truck drivers and vets with seasonal second homes. Many Florida/New Jersey snowbirds are registered at two VA's, and they call ahead to ensure they'll have authorizations for Fee Based dialysis when they arrive. Here's a point to remember: Although your home VA can issue you authorizations for non-emergency care anywhere you go, it's different for emergencies. When you go to a non-VA ER, the nearest VA Facility of Jurisdiction runs that show. The hospital will send notification to the nearest VAMC for approval, and that's the VA that will pay the bills. (Since you're probably not in that VAMC's database, you will need to be registered so that VAMC can pay the bill.) Although P&T vets aren't required to be enrolled in the VHA system prior to an emergency, it helps to smooth the process of paying the bills. Just be sure it's really an emergency. When you're P&T, or receiving Homebound/Aid & Allowance, or if you're 50% SC or more, you don't have to use your Medicare if you don't want to. But you must contact the nearest VA within 72 hours of arriving at the ER. If you forget your meds, your home VAMC can still help out. Locate a big national chain pharmacy, and ask them to fax a request to your home VA. The bigger chains can take prescriptions from most states. Remember that your VA doc is probably only licensed in one state, so pick a chain that can accept scrips from that state. ============================= Thanks VABA, I do travel and into another jurisdiction other than the one here in East Tn.. where 100% of all medical care is done being P&T , including outsourceing to private medical, dental, eye clinics etc.. While in the Carolinas, I would be closest to Charleston, SC VAMC and so I got this email from the civilian med. center in Myrtle Beach where I go alot. =========================== > If you are 100% total disabled from the VA they you can use this facility in an emergency. There is a VA clinic in Myrtle Beach on "the old Air Force base" which is now Market Commons. To verify the VA benefits we would contact the VA in Charleston. We would also need to know the office/clinic/hospital that you normally use. Jude A. Dunn Grand Strand Reg Med Ctr 843-692-1730 ------------------------- > As you explained, If I were in this area a couple times a year, would I need to "register" with the Charleston and/or Columbia, SC VAMCs? This is a very good thread, my bottom line is, if necessary, I will call e911 and as you say, tell them/show your va id and get care no matter where. worry about money later, life can be a one time thing.
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VABA	Multiple VAMCs	#25	[url]	[-]
Posts: 2510 Jan 11 11 12:25 AM	Stash, I think you've got the idea. Stop by the enrollment office at your favorite VAMCs. Some vets anticipate their traveling needs by getting the home VAMC to authorize their weekly dialysis in the cities they are going to visit. Road warriors keep a copy of their medical records with them. StarLite, good luck with your appeal. I'm thinking that perhaps the VAMC paid the ER portion at the first hospital, but then refused the inpatient portion at the second hospital, yes? The definition of "emergency" changes. To pay an outpatient emergency room visit, the Utilization Review nurse uses the "prudent layperson" standard. But inpatient stays must meet a stricter "clinical emergency" standard.
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Starliteman	VABA Reply to 1-11 response	#26	[url]	[-]
Posts: 63 Jan 25 11 5:19 PM	Hey Man, Sorry I didnt see your response to me due to it was hooked in to your response to Stash. Fee Basis did not pay either hospital bill on that episode. I did not know what was going on in this situation, I was distracted just dealing with my health issue. All I know is that I did not have any options in how I was being treated. I was somewhat stabilized in the first emergency room and the ER doctor ordered for me to be transfered to second hospital because the first hospital could not handle my ongoing problem. I was amulanced to 2nd hospital with IVs and that hospital cardiology team set me up for surgery ASAP. However, even then the VA was notified where I was, and again I was just doing what the medical professionals said we had to do. I had no alternative. I have since been SCd for the atrial tachyardia at 30% the highest rating posible for that condition. What would the criteria be as far as emergent at the second hospital and how could one have done anything different?? Thanks, Ron
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VABA		#27	[url]	[-]
Posts: 2510 Jan 26 11 7:42 AM	The way I see it: a) You were 50% SC for a single condition on the day of the emergency. In fact, you were seeking care for a SC disability, your heart. b) An ambulance crew determined you were indeed in need of care at the nearest ER and took you there. c) You notified the Department of Veterans Affairs within 72 hour of arriving at the ER. d) Completed claim on proper forms with medical records were delivered timely. So a, b, and c fulfill the requirements of USC 1703 and payment for the care should have been granted. e) At the time you were in the first hospital, the VA had the opportunity to request your transfer to a federal facility, but did not. f) Within hours of arriving at the ER, still in emergent status, the ER doctor ordered your immediate transfer to a hospital capable of the life-saving care you needed. g) At the second hospital, doctors treated you for an emergent condition arising from a service-connected disability (your heart). h) The VA had the opportunity to transfer you once you were stable, but did not. So the VA should pay this entire episode of care, from start to finish, within 30 days of receiving the UB-04 claim form for hospital care and the CMS-1500 claim forms for medical services and the trip report/bill for the emergency transportation. The initial denial was a clear VA error, and Fee Basis should have paid the claims the first time you requested reconsideration, upon receiving your NOD, without requiring the lengthy, time-consuming, expensive and credit-damaging delay of sending your case to BVA. If you suffered any adverse credit action, the Fee Basis supervisor is responsible to investigate, including communicating with the collection agencies, taking responsibility for the debt, and requesting your credit record be corrected. Sound about right?
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Starliteman	VA Error	#28	[url]	[-]
Posts: 63 Jan 26 11 6:11 PM	Appreciate your response, All Sounds good except my disability percentages. At the time I went through this episode I was rated 10% for tinnitus bilateral and 10% hearing. Total 20%. However I did meet the critera for payment. A: I was responsible for to the provider for payment. B: I was enrolled in va healthcare. C: I had no other insurance or means to pay bills. D: VA facilities were 80miles away, and quite appearent I was in an emergency situation. Flowood Ms. fee basis did not appearently did not have a problem with the above except they deemed I was non-emergent ???? One way to refuse I suppose. the letter did state "This claim was reviewed by SCVAHCN Consolidated Fee Clincal Coordinator and reviewed for reconsideration by SCVAHCN Business Manager and it was determined that the veteran did not meet the criteria to entitle payment for medical treatment under the title 38C.F.R. 17.1000-1008." Reason for Decision: Uder the law in order to be entitled for payment of the cost of unauthorized medical expenses(38CFR 17.52) and claims applicable to the Millennium Act (USC 18 17.1000-1008) all the criteria listed above must be met. Failure to satisfy criteria will result in claim being disapproved. Non-emergent care. On another letter it says "Reasons for not approving claim: Medical treatment was for non service connected condition which was clinically determined not connected to his service connected disability, A medical emergency must have existed. Care and services were not rendered in a medical emergency of such nature that delay would have been hazerdous to life and health." On a side note at the time I had a claim in for PTSD that did not show in the system at the time but was granted 50% after this incident but was backdated to May 21,2009. This emergency took place in June 2009. So technically I was @ 60% at the time but it did not show. I was not connected for heart condition till Feb 2010.. It was granted secondary to PTSD 30% I am now 80% @100% TDIU PT Also I had been in on the first same exact issue apprx a month earlier and they paid that one with no questions This unpaid is the second same issue that they decided not to pay. I also went in the third time for this eaxct same issue but I was stablized in the local ER and was ambulanced to Muskogee RO first, they could not handle my problem and ended up sending me to the same 2nd hospital in Tulsa that had worked on me on the other two visits. I ended up through all this, having 3 heart ablations various meds and the last visit I had a pacemaker with overdrive implanted, and so far I am somewhat O.K. Any Ideas??? Thanks for Responding and helping me. Ron
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VABA	Woo hoo. You can win.	#29	[url]	[-]
Posts: 2510 Jan 26 11 8:21 PM	And it's a whole new ball game! If you were not seeking emergency care for a service connected condition, nor were you 50% SC at the time, then you were seeking UNauthorized emergency care for NSC conditions, which is payable under the conditions in 38 USC 1725, the Veterans Millennium Health Care and Benefits Act (Mill Bill). That's a whole 'nother can'o'worms. The Mill Bill is designed for vets who have NO healthcare insurance and are seeking emergency care for Non-Service-Connected conditions. To qualify, you must meet all of these criteria: You were provided care in a hospital emergency department or similar facility providing emergency care. You are enrolled in the VA Health Care System. You have been provided care by a VA health care provider within the last 24 months (but C & P, Agent Orange, Ionized Radiation and Persian Gulf exams don't count) You are financially liable to the provider of the emergency treatment for that treatment. You have no other form of health care insurance. You do not have coverage under Medicare, Medicaid, or a state program. You do not have coverage under any other VA programs, like Ch 31 training or CFR 1703 "authorized" or 1728 "service connected" stuff You have no other contractual or legal recourse against a third party (such as a Worker’s Comp Claim or a Motor Vehicle Accident) that will pay all or any part of the bill. Department of Veterans Affairs or other federal facilities were not feasibly available at time of the emergency. THE BIG DEAL IS: The care must have been rendered in a medical emergency of such nature that a prudent layperson, with an average knowledge of health and medicine, would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health. YOU HAVE AN EXCELLENT CASE! There is no way they can deny this, because a trained EMT made a professional determination that you needed to be seen fast, sirens and lights, at the nearest ER. The Mill Bill only requires a "prudent layperson" to "reasonably" expect... You did that. The EMT did that. And in fact, the ER doctor, an expert in recognizing life and death situations, called for an ambulance to take you. It is totally out of line for the to second-guess you, the EMT, and the ER doctor, when the standard to be met is the "prudent layperson" standard! Screw the NOD and appeal. Just fax their letter, and your response about the prudent layperson, to the VAMC director and "respectfully request" that he help his Fee Coordinator understand the regulations prior to taking on the responsibility for delivering healthcare to thousands of veterans who depend upon his/her knowledge of the Code of Federal Regulations. But wait, there's more! What is the effective date of your service connection for heart? That's another option for another day. G'nite. Edited 1 time by VABA Jan 26 11 8:23 PM.
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Starliteman	Effective Date Atrial Tachyardia	#30	[url]	[-]
Posts: 63 Jan 26 11 9:06 PM	Man I do appreciate your guidance on this matter. The effective date on Atrial Tachyardia secondary to PTSD @ 30% is 2-11-2010
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VABA	Go with it and tell us how it goes.	#31	[url]	[-]
Posts: 2510 Jan 26 11 10:25 PM	Starliteman wrote: Man I do appreciate your guidance on this matter. The effective date on Atrial Tachyardia secondary to PTSD @ 30% is 2-11-2010 IF, on the date of the emergency, you were 50% SC for a single disability, then you can use 38 USC 1703, but you shouldn't have to, now. 1703 can pay for emergency care for any disability, and is not limited to SC conditions, even if the vet isn't enrolled and isn't active. But the emergency must meet a "clinical definition" which is much more stringent than the "prudent layperson" definition. The VA can more easily second-guess a doctor's determination in this case. I still stand by my post titled "Woo Hoo." Go for it.
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Starliteman	Response to VABA	#32	[url]	[-]
Posts: 63 Jan 27 11 8:54 AM	VABA, I will do just as you instructed and will let you know how it turns out. I will start my own thread on this when I am able to inform any future information. Thanks a million for your insight. Ron
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Survivir		#33	[url]	[-]
Posts: 10258 Jan 27 11 7:28 PM	Thank you Very Much VABA. This is Really Great Information. I have add this Thread's Link...to the "Hidden Benefits" Thread. Survivir
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FAS wife	I was just reading this very interesting thread	#34	[url]	[-]
Posts: 2 Jan 28 11 1:04 AM	and wanted to relate an opposite example to the ones I have read. I am 70% serviced connected and requested TDIU. I had my C & P exam on the 25th of Aug. On the 26th of Aug I was helping my son move to Washington state from Kansas. By the time I got to South Dakota the C & P doctor called me and told me that my blood pressure was high and that he could not turn in his report until he had three consecutive blood pressure readings and could I come back to have it done. I told him that I was out of state but there was another VA hospital nearby. He told me to go there and have it done. I did and then had another one taken in Spokane. The other day my wife gets a letter from her insurance saying that they are not going to pay a bill for several hundred dollars that I incurred for getting my blood pressure checked at the VA hospital. I am on my wife's insurance and handed over my card when they asked for it not knowing they would be billed. I thought the price was pretty high for a blood pressure reading, but I now know that they have to make up the difference for all the money that they are paying to civilian hospitals. I just realized that I inadvertently used my wife's account to post and don't want to retype this as I am no good at it. Please forgive.
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VABA	Check your VA bill.	#35	[url]	[-]
Posts: 2510 Jan 28 11 5:30 AM	Here are some representative costs, so you can see how much VA charges for care. Services provided by a primary care clinician are $15 for each visit. Services provided by a clinical specialist are $50 for each visit Preventive care services (such as screenings and immunizations) are free. The INpatient co-payment is calculated by adding $10 per day of hospitalization (in 2009), and $1,068 for the first 90 days of hospitalization and $534 for each additional 90 days (in 2009). A veteran who is 50 percent disabled or more with a service-connected disability does not have to pay anything for medications. The highest charge for medications is $8 (in 2009) for each 30-day or less supply of medication. You will not be charged more than $960 during the calendar year. The first 21 days of long-term care are free. Co-payments start on the 22nd day
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theoddz		#36	[url]	[-]
Posts: 13 Feb 27 11 12:47 PM	I am 100% P&T (schedular), plus get both S and K awards, again, P&T. A couple of years ago, I got really sick (asthma/pneumonia) and since I live by myself, was too sick to try to drive myself to the VA hospital (where I work). I called 911 and an ambulance took me to another local non-federal hospital, and there I stayed for several days. I did show my VA ID card in the ER I was taken to, and did NOT show them my private insurance card I have from work. When I got out of the hospital, I was told that my bill would be 100% paid by the VA, since I am 100% SC, P&T. I didn't get any bills for the longest time, but after several months, I received, from the local VA Fee Basis Dept., a manila envelope in the mail, filled with letters of denial for the costs of that hospitalization, right down to the ambulance bill. I thought, "WTF"?? Their reason for denial was "Veteran has other health insurance". Well, I first tried calling the Fee Basis department, but they don't allow Vets to call and talk to a rep there right away. They have an "operator" who says that he/she will "take your number and have a rep call you back within 7-10 business days". The operator I talked to, however, told me that "it'll probably be longer". Well, that really pissed me off, because I was now receiving letters from collection agencies for some of these bills and I have really great credit and that's hard to come by, these days!! I got to thinking, in my anger, that I'd probably get faster attention from my local congress representative!! As it just so happened, my Congresswoman, Rep. Shelley Berkley (D-NV) is a GREAT friend to us Veterans and both she and Harry Reid have been the key players in getting us Nevada Veterans a new VA Medical Center, here in Las Vegas. Ms. Berkley was holding a constituent's meeting ("Congress on Your Corner" style), which she regularly has, here in Las Vegas. I gathered up those bills, the notes of my correspondence from the VA, my rating letter, and I went down to see her. Long story made short........within 2 weeks, I had a letter in my hand from the Director of the VASNHCS to both Ms. Berkley and myself, apologizing for the "mistake" and for "any inconvenience to Mr. ****", and that "a VA representative will notify the billing department of the local hospital where I received care and also any creditors/collection agencies that were now involved in this matter and have ALL bills connected with this hospitalization paid in full immediately"!!! As a result of all of this, I now know and have a good friend in my Congresswoman, Ms. Shelley Berkley, and have been told that, if I EVER have any more problems like this, or any other problem in getting care from the VA, to let her know and it will be resolved immediately!!! So, that's another avenue of redress we Vets have when there are problems with the VA. I realize that not all of us have transportation or are physically able to go down and personally meet our elected folks, but we can and SHOULD call and write letters and otherwise get to know them!! They really want to help us. We're a huge voting block and our voices count!! We served and fought for this country and now we need the help we have EARNED. Semper Fi. (yep, I'm an old Jarhead)
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VABA	The HORROR...the horror.	#37	[url]	[-]
Posts: 2510 Feb 28 11 1:51 AM	What a horror story. The callousness, poor management, lack of response, and the downright obviously WRONG fee basis decision you describe make me shake my head in disgust, then shake my fist in anger. I'm working everyday to clean up this kind of credit mess for my fellow veterans every day. Thanks for the example.
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mazboy		#38	[url]	[-]
Posts: 740 Feb 28 11 7:14 AM	hey, it just happened to me. i went into an ER saturday for and emergency and they did not accept my VA card. I am 100% disabled, not retired. well, today i will try to get with the VA and submit my bill...hope the VA will pay.
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Skinny Cat		#39	[url]	[-]
Posts: 1952 Mar 1 11 8:11 PM	I'm 100% P&T as well, have SSDI and Medicare A&B plus privet Insurance through my wifes work at the state. If I'm reading this right, theoddz called 911 and was excepted into a hospital using his VA ID card and told no one he was covered by a privet insurance company. Question#1. Who told you since you were 100% P&T, VA would pay all the pills, someone at the hospital? Question#2. VA Fee Basis denied they would pay any of your bills so you needed to contact your Congresswoman to get things payed for by Fee Basis? So do we need to keep our Congressman's phone # on the back of our VA hospital card? I agree that Fee Basis will not answer your request for any kind communication regardless of how often and who you try to contact there. Question 3. I just signed up for VA health care. Just how much insurance do I need if I can get everything payed for using my VA ID card and my Congressman's influence? Do I really need Medicare A&B, privet health insurance, and VA Health Care? I just read I need a supplemental insurance to cover the extra cost that Medicare doesn't cover! I've always considered insurance to be a scam, but this is getting ridicules! For those who fought for it, freedom has a meaning the protected will never know.
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herdgrunt		#40	[url]	[-]
Posts: 5807 Mar 19 11 12:41 AM	Skinny, yes, insurance is a scam and it has all gotten ridiculous. What you need may be differenct from others and also what you qualifiy for is also most likely different. First of all, you get Medicare A automatically if you are SSDI, Part B you opt in for so that's your choice but if you refuse initially, it gets more expensive later on. If you are paying for private healthcare insurance then you have private healtcare options, usually with copays. If you have VA at 100% eligibility, then you will not have copays on care and meds and you will not have any premiums either. So, long and short, exactly what are you needs and want to cover for. Medicare B, Private Insurance, and VA is more than one needs, something is redundant but at lease all scenarios would be coveredl ",.....with the cross of Jesus, going on before."
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