A 21st Century System for Evaluating Veterans for Disability Benefits (2007) / Chapter Skim
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5 The Medical Examination and Disability Rating Process
5 The Medical Examination and Disability Rating Process
Pages 139-200
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From page 139... ...
The objective most relevant to the disability compensation program is objective 1.2: "Provide timely and accurate decisions on disability compensation claims to improve the economic status and quality of life of service-disabled veterans" (VA, 2006c)
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From page 140... ...
Service administers the disability compensation program. C&P Service also administers the dependency and indemnity compensation, death compensation, disability pension, death pension, burial benefits, automobile allowance/adaptive equipment, clothing allowance, and specially adapted housing programs.2 Each regional office includes a veterans service center (VSC)
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From page 141... ...
(GS-11) ; Prior to this, regional offices had more latitude to vary their organization and procedures.
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From page 142... ...
This team is responsible for most of the medical development activity in the following cases: • original and reopened compensation; • compensation claimed due to injury or death caused by VA medical care or evaluation; • original and reopened disability pension; • original and reopened dependency and indemnity compensation (DIC) ; and • basic eligibility issues requiring a rating decision.
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From page 143... ...
This team also completes entitlement determinations for issues that do not require a rating, such as • accrued benefits; • apportionment decisions; • competency issues; • income changes; • original pension; • dependency issues; • burials; The rating process, which involves the interpretation and application of VA's Schedule for Rating Disabilities, is described in more detail later in this chapter.
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From page 144... ...
They conduct interviews, identify issues, gather relevant evidence, adjudicate certain claims, authorize payments, and input data for award generation and notification of the veteran. However, the key staff person in the actual disability rating is the RVSR, who is on the
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From page 145... ...
The RVSR determines • service connection; • percentage of disability; • permanent and total disability; • entitlement to compensation, pension, and vocational training; • medical and dental treatment; • automobiles or other conveyances; • insurance; • specially adapted housing; • dependent education allowances; and • other ancillary benefits. There are also RVSRs on the triage and predetermination teams because those teams perform a limited number of the ratings in certain circumstances and also assess whether the medical evidence is sufficient to support a rating decision.
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From page 146... ...
It currently operates under a 2004 memorandum of agreement between VA and DoD to create a cooperative separation medical examination process to ease the transition from service to veteran status. The BDD program "enables separating service members to file disability compensation claims with VA staff at military bases, complete physical exams, and have their claims evaluated before, or closely following, their military separation" (U.S.
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From page 147... ...
The team sets diaries (deadline dates) for receipt of requested information, then determines the need for a VA medical examination to assess the current level of disability or to provide a medical opinion about whether the current disability is related to the veteran's military service (referred to as "medical nexus")
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From page 148... ...
The person who decides your claim (called a Rating Veterans Service Representa tive) may order a medical examination.
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From page 149... ...
. Generally, the predetermination team in the regional office's VSC determines the kind of examination needed based on the available medical records and uses one or more of 58 examination worksheets (referred to as AMIE worksheets, after the Automated Medical Information Exchange system for which they were originally developed in 1997)
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From page 150... ...
The VHA health-care facility decides who will perform the examination and where and how the examination will be conducted. The regional office may request specific specialist examinations, but the physician examiner may also decide if a specialist examination is necessary on a
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From page 151... ...
. If the examination is being conducted on a remanded case, BVA usually requires the examiner to review the entire claims file, including service records, medical records, and previous C&P examination reports.
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From page 152... ...
If an examination report does not include sufficiently detailed information to support the diagnoses or about the effects of diagnosed conditions on functioning, the RVSR is instructed to return the report as inadequate for rating purposes. VHA Examiner Qualifications, Training, and Quality Assurance Training and qualifications of examiners who perform C&P examinations in VHA are monitored by CPEP, a joint initiative between VHA and VBA established in 2001 to improve the C&P examination process.
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From page 153... ...
QTC Examiner Qualifications, Training, and Quality Assurance QTC Medical Group, Inc. currently provides C&P examinations for 10 VA regional offices and 26 BDD sites, using a network of approximately 1,600 contracted private practitioners.
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From page 154... ...
. THE DISABILITY RATING PROCESS After all development actions are complete, the VSC predetermination team refers the claim to the rating team for a rating.
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From page 155... ...
. • Rating agencies will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension.
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From page 156... ...
The discussion above shows that the rating process is complicated and multifaceted. The technicians who execute the ratings are expected to have substantial expertise in VA law and the medical aspects of the Rating Schedule.
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From page 157... ...
Supreme Court. Although a veteran can appeal for any reason, issues frequently appealed include disability compensation, pension, education benefits, For a detailed description of the appeal process, see BVA (2000a)
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From page 158... ...
the VA regional office denied them benefits for an impairment (i.e., it was declared not to be service connected) that they believe began while they were in service, and (2)
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From page 159... ...
BVA reviews all appeals for entitlement to veterans benefits on behalf of the VA secretary, including appeals involving claims for service connection, increased disability ratings, individual unemployability, pension, insurance benefits, educational benefits, home loan guaranties, vocational rehabilitation, and dependency and indemnity compensation, and also determinations of duty status, marital status, dependency status, and effective dates of benefits. In FY 2005, 94 percent of the cases were appeals of compensation decisions by regional offices (Terry, 2006a)
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From page 160... ...
Each VLJ is expected to complete a minimum of 752 decisions per year as his or her "fair share" of BVA's total workload and conduct three one-week travel boards to regional offices. Counsel, who draft decisions, are asked to draft at least 156 decisions per year (Terry, 2006b)
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From page 161... ...
. These included 37,295 decisions on compensation cases, of which • 20 percent involved a grant on at least one issue; • 46 percent involved a denial of all issues; • 32 percent involved a remand to the agency of original jurisdiction, meaning the regional office; and • 2 percent were classified as "other" (BVA, 2006)
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From page 162... ...
The Medical Advisor also provides training on medical issues to the Board's VLJs and staff counsel. Additionally, he is available to consult with staff counsel and VLJs to read medical records and provide back ground information and training on medical issues encountered in review of particular claims.
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From page 163... ...
BVA may favor the opinion of one competent medical expert over that of another when adequate reasons or bases are provided. Factors weighed include • competency of the medical professional or medical evidence provided; • use of the correct factual history; • adequacy of supporting analysis or basis provided for opinion; • consideration of a review of the claims file or a full history of the disability; • whether the clinician is the veteran's treating physician and familiar with his or her medical records and history; • level of thoroughness and detail of opinion; • equivocality of the opinion; • personal interest in the case on the part of the opinion provider; • special qualifications or expertise of the opinion provider; • contradictory or internally inconsistent statements; • differentiation among multiple opinions based on rationale or analyses; and • consideration of the benefit of doubt rule if there are multiple conflicting medical opinions (Terry, 2006a)
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From page 164... ...
Court of Appeals for Veterans Claims. If BVA denies requested benefits, or it grants less than the maximum benefit available under the law, and the veteran decides to appeal to the CAVC, he or she must file the appeal within 120 days after BVA mailed its decision.
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From page 165... ...
BVA training sessions held during the past two years on medical and legal topics involving medical matters included • introduction to medical terminology; • secondary service connection/Allen cases; • presumption of service connection and applying rating criteria when there has been a change in the law; This standard was adopted in 2002 after the Government Accountability Office (GAO) suggested it; previously, non-substantive errors, such as using the wrong format, were counted against the accuracy rate (GAO, 2002a, 2005c)
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From page 166... ...
; • multiple opinions -- assigning credibility and weight of the evidence when reviewing; • special monthly compensation and adaptive equipment; • respiratory disorders; • rating knee disabilities; • total disability ratings based on individual unemployability; and • hearing loss and tinnitus. DISABILITY CLAIMS PROCESS ISSUES: TIMELINESS, ACCURACY, AND CONSISTENCY Veterans deserve a claims process that is efficient and fair.
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From page 167... ...
167 THE MEDICAL EXAMINATION AND DISABILITY RATING PROCESS General (OIG) reported that 24 percent (95,000 of 405,000)
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From page 168... ...
. CPEP is also addressing the adequacy of regional office requests for C&P examinations.
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From page 169... ...
VBA has been unable to track total number of issues adjudicated until recently, with the advent of the current tracking system, RBA 2000. According to data provided to the committee by VBA, adjudicators made more than 1.8 million rating decisions on compensation for disabilities during calendar year 2006, while adjudicating 628,000 disability compensation claims, indicating that the average number of issues (disabilities)
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From page 170... ...
. In 1993, the deputy under secretary for benefits appointed a blue ribbon panel on claims processing to find ways to decide disability decisions more quickly.
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From page 171... ...
, which reported in 1997.23 VBA regional offices were reorganized along case management lines, to ensure that someone was accountable for each case as it went through the decision-making process, and a major effort to improve the timeliness and quality of C&P examinations was launched (discussed earlier)
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From page 172... ...
, but also a number of other steps to reduce the backlog of pending claims. These included • creation of "tiger teams" in the Cleveland regional office and estab lishment of nine resource centers to focus on processing cases of claimants over age 70, and then claims older than a year; • establishment of appeals claims processing teams in all regional offices; • faster record recovery from the VA Records Management Center; • better training; Additional factors slowing production were the time needed for staff to learn RBA 2000 and for training a substantial number of new VSC staff (GAO, 2002b)
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From page 173... ...
Appeal Workload and Timeliness As discussed earlier, veterans dissatisfied with the decision made by the regional office may file an appeal by submitting an NOD contesting the denial of service connection, rating level given, or effective date of the grant. According to BVA, the appeal rate on disability determinations has historically been about 7 percent.
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From page 174... ...
As a result, the number of cases pending at BVA at the end of FY 2006 -- 40,265 -- was almost double the number at the end of FY 2000. This does not include the substantial number of appeals being worked on by the appeals teams in regional offices and the Appeals Management Center, which was established by VBA in 2003 to consolidate expertise in processing remands from BVA (Figure 5-6)
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From page 175... ...
175 THE MEDICAL EXAMINATION AND DISABILITY RATING PROCESS 18% NOD Filed 16% VA Form 9 Filed 14% 12% Rate of Appeals 10% 8% 6% 4% 2% 0% 2000 2001 2002 2003 2004 2005 2006 Fiscal Year FIGURE 5-4 Rate of appeals (NODs)
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From page 176... ...
, total appeals requiring adjudication. 5-06 reversed the field office decision on one or more of the issues 20 percent of the time, and remanded the case to the originating field office 32 percent of the time for further development of one or more issues (VA, 2006a:19)
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From page 177... ...
At the end of FY 2006, 16 percent (21,200 of 133,600) of the rating-related claims pending at regional offices and the VBA Appeals Management Cen
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From page 178... ...
If, as expected, 75 percent of the remands are returned to BVA after further development, they will constitute 30–40 percent of the 35,000–40,000 cases decided by BVA each year (in FY 2006, for example, BVA received 14,400 remands returned by the Appeals Management Center and regional offices for decision, equal to 37 percent of BVA decisions that year)
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From page 179... ...
The reasons given were separated into "before certification" and "after certification," on the grounds that the causes of avoidable remands that happened before they were certified and transferred by regional offices to BVA should be in the control of, and therefore could be prevented by, regional offices. The initial analysis of 200 remand cases identified 379 precertification reasons for the remands.
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From page 180... ...
180 EVALUATING VETERANS FOR DISABILITY BENEFITS 50,000 2004 2005 2006 45,000 Number of Remand Reasons -- Precertification 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Other Medical Records Related C&P Medical Examination All Reasons Opinion Related Remand Reason FIGURE 5-9 Number of remands by reason, FY 2004–FY 2006. NOTE: Other medical records include military service, VA, and private medical records that should have been requested but were not, or if requested but not 5-9 forthcoming, were not followed up.
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From page 181... ...
NOTE: Documentation and notification were included in the entitlement accuracy rate until FY 2002. The 2001 Claims Processing Task Force recommended that VBA 5-10 measure them separately so that the benefit entitlement accuracy rate would only include items that, if inadequate, could result in remand from BVA.
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From page 182... ...
Offices with low accuracy rates are required to implement corrective action plans. Trends in error types are used to design national training programs and to identify needed regional office-specific training, which is offered during site visits (VA, 2007a)
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From page 183... ...
. The 2001 VA Claims Processing Task Force recommended that VBA evaluate and address inconsistencies among regional offices.
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From page 184... ...
The inspector general examined a number of explanations for the variation in payments besides inconsistencies in disability ratings among regional offices, including demographic differences (such as the percentage of veterans in a state's population, their period of service, and their average age) and process factors (such as percentage of claimants with representation, percentage of raters with more than two years of experience, and appeal rates)
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From page 185... ...
The rate of service connection for PTSD also varies by state, ranging from 4.1 per thousand resident veterans to 25.5 per thousand resident veterans. The results for individual unemployability (IU)
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From page 186... ...
. The 1991 Claims Processing Task Force
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From page 187... ...
SOURCE: BVA Diagnostic Code Distribution Report, October 1, 2005–May 31, 2006. 100% 90% Adequately Addressing DeLuca Criteria, FY 2004 Percent of Spine and Joint Examinations 80% 70% 60% 50% 40% 30% 20% 10% 0% M an n 6 16 18 5 8 17 2 7 9 4 15 3 10 12 21 11 23 20 1 9 22 ia e ed M Veterans Integrated Service Network FIGURE 5-13 Percentage of spine and joint examinations adequately addressing DeLuca criteria, by VISN, FY 2004.
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From page 188... ...
In 2003, as discussed previously, VBA established the Appeals Management Center to help process remands. VBA centralized dependency and indemnity compensation claims by survivors of servicemembers who die on active duty in a casualty assistance unit in the Philadelphia regional office.
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From page 189... ...
It requires the predetermination team to request the correct information needed from the medical examiners, examiners to conduct thorough examinations and report the results completely and accurately, and raters to interpret the medical information in light of the criteria in the Rating Schedule. It also requires VHA to ensure that the expertise of the examiner or examiners is appropriate for the condition or conditions being evaluated, especially for complex conditions such as PTSD, TBI, and polytrauma encountered in veterans of the current wars in Iraq and Afghanistan.
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From page 190... ...
The VA undersecretary for benefits concurred with this recommendation, and stated: We will continue to work with the Veterans Health Administration to improve the quality of medical examinations performed to support dis ability compensation evaluations. We will work with the CPEP Office to ensure that all automated examination report templates thoroughly and accurately solicit the medical evidence needed to consistently evaluate the disability.
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From page 191... ...
The next step would be for VA to make the quality of examination requests part of the performance program for predetermination teams and regional office directors. In addition, the QR program currently does not directly assess consistency among examiners.
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From page 192... ...
Although this represents substantial improvement, it still shows that one of every nine rating decisions is incorrect, and this leaves considerable room for further improvement. In addition, the STAR accuracy rate is based on a relatively small sample -- only large enough to determine the aggregate accuracy rate of regional offices.
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From page 193... ...
The adoption of the CPI model by all regional offices in 2001–2002 is an example of this approach, but there is still evidence of considerable variation across regional offices in decision outcomes, such as grant rates, rating levels, and rates of appeals. VA should study these variations and identify best practices for all offices to adopt.
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From page 194... ...
. These are in addition to arrangements for independent medical examinations where needed to provide missing or inconsistent medical information.
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From page 195... ...
BVA also has an extensive training program, part of which is given by an on-staff medical adviser, a physician who also acts as an informal adviser to VLJs and counsel in a role somewhat like the medical consultant role recommended in Recommendation 5-4. The QR programs of both VBA and BVA are used to identify training needs, whether on particular topics or at particular regional offices.
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From page 196... ...
Presenta tion to the Veterans' Disability Benefits Commission, Washington, DC. http:// www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/ Documents/June_ 2006/CPEPBriefing_June2006.pdf (accessed March 2, 2007)
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From page 197... ...
2007. Veterans' disability benefits: Long-standing claims processing challenges persist.
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From page 198... ...
Presentation to the Veterans' Disability Benefits Commission. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/ Documents/June_2006/QTCOverview_June2006.pdf (accessed March 2, 2007)
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From page 199... ...
compensation and pension examinations. http://www.ptsdmanual.com/ptsd.pdf (accessed March 20, 2007)
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From page 200... ...
2005b. Department of Veterans Affairs Office of Inspector General review of state vari ances in VA disability compensation payments.
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