VA whistleblower exposes improper claim rejections

KARE 11 Investigates ER bill denials for veterans

Minnesota veterans are being saddled with medical debt they should not owe - some of it even turned over to collection agencies - after trips to the emergency room. http://kare11.tv/2fuadqu None

MINNEAPOLIS - Minnesota veterans are being saddled with medical debt they should not owe – some of it even turned over to collection agencies – after trips to the emergency room.

Current and former VA staffers tell KARE 11 it’s happening because medical claim processors at the Department of Veterans Affairs (VA) are pressured to review complicated files in just minutes.

To meet performance goals, they say it’s quicker to deny claims than to take the additional steps needed to approve payments.
   
“We are accountable for speed,” one VA insider told KARE 11 in an exclusive interview.

RELATED: A pattern of denial: One veteran's story

KARE 11’s ongoing investigation has documented a pattern of denials that raise questions about how well the VA is processing emergency care claims and whether thousands of veterans nationwide are being left liable for millions of dollars in unpaid medical bills.

Two recent cases in Minnesota illustrate the problem.

Improper Denials

When you are parents of a newborn, there can be a lot of sleepless nights. But for Ben and Gretchen Krause, one night last February stands out.

Ben and Gretchen's story: VA denies ER payments, calls vets imprudent

“The idea of losing him, Ben, with a little baby here. It was really scary,” said Gretchen, fighting back tears.

“I remember he said, ’Something’s wrong, something’s wrong,’” recalled Gretchen.

Fearing he was having a heart attack, she rushed her husband to an emergency room just minutes from their Woodbury, Minnesota home.

“I felt like my chest was about to pop,” Ben said.

Doctors at HealthEast’s Woodwinds Hospital determined Ben was having an extreme form of stress likely exacerbated by a recent death in the family.

“Technical term for it is malignant hypertension with neurological and cardiovascular complications,” Ben explained. “I couldn’t dial back the stress from what was going on in the grief process.”

As a service-connected disabled veteran, Ben rightly expected the Minneapolis VA would automatically pick up the $6,066 hospital bill.

Instead, he received a denial letter.

Ben’s story sounds all too familiar to Bob Ramsey of Ramsey, Minnesota.

He has a blood disorder that can lead to potentially deadly clots.

“I was always warned if I had any issues with my leg, pain, things like that that I should be seen immediately because I could have a blood clot,” Bob said.

Bob's story: Vet turned over to collections after VA bill denial

About a week after having knee surgery at Maple Grove Hospital – a surgery the VA paid for under its Veterans Choice program – Bob says he experienced growing pain in his calf.

“I thought, well, I better call the VA and see what they want me to do,” said Bob. “And so, I called the VA and the help line.”

He says he spoke with the triage nurse on duty.

“She said, ‘Well, you should go in and be seen right away, but you should go back to where you had the surgery.’ And so, that’s what I did,” Bob recalled.

Bob said since he’d called the VA to ask what he should do, and then followed the instructions he was given to seek private emergency care, he expected the VA would pay his bill.

He was wrong. The Minneapolis Non-VA Care Department sent him a letter denying his claim. 

Bob said he tried reasoning with the VA for nearly a year.  Meanwhile, his unpaid bill from Maple Grove Hospital was turned over to a collection agency.

“Those people are hounds!” he said. “They’ll continue to call and harass you.”

“This is your bill, you should pay for it. You’re a bad person because you didn’t pay your bills,” Bob recalls being told.

But shortly after KARE 11 began investigating, the Minneapolis VA did a sudden about-face. The VA admitted the denials were mistakes and agreed to pay both men’s ER bills. 

Bob received a voicemail from an official who identified himself as Minneapolis VA Patient Advocate Michael Rosecrans.

“Hey, I just want you to know that the claims – the ER emergent care claims – will be processed today for payment,” the caller said.

Ben Krause said he received a similar phone call.

“The second that they realized that somebody was looking into it, and somebody with the ability to make it into a national story, once they realized that, then they called and said, ‘Oh sorry, we made a mistake, we’re going to take care of it.’”

After KARE 11 reported their stories, dozens of other veterans from across the country contacted our investigators saying their claims also had been wrongly denied.

A whistleblower's explanation

Our search for answers into why the mistaken denials are happening, led KARE 11 to a VA employee who worked as a voucher examiner in the VA’s Office of Community Care. That is the office responsible for denying Bob and Ben’s claims.

The employee named Joe spoke with KARE 11 on the condition that we not use his last name.  He had seen our reports and told us he had a painful confession to make.

“It’s been weighing on me a lot,” he said.

Joe said he’s troubled because he believes there are a lot more veterans who, like Bob and Ben, have been stuck with emergency medical bills the VA should have paid.

“You know for a 100% fact that there are claims being done incorrectly?” asked KARE 11 Investigative Reporter A.J. Lagoe.

“Yes,” Joe responded.

Lagoe: “Because you’ve done them incorrectly?”

Joe: “Yes.”

That admission is in direct conflict with Joe’s 2016 VA Employee Performance Appraisal.  In glowing terms, it rated him an “exceptional” employee.  A supervisor wrote that Joe maintained an “excellent claims processing accuracy average at 99% which exceeds the national standard for the exceptional rating.”

Lagoe: “Is that true?”
Joe: “Probably not.”
Lagoe: “How do they monitor errors?”
Joe: “We don’t.”

The VA’s emphasis, Joe says, is on a quota system that tracks how many claims its examiners complete each hour.

“We are accountable for speed,” Joe told KARE 11. “And the faster you are, the more your performance goes up -  your review does, you get a bonus.”

Faster to deny

Joe’s 2016 performance review shows that in order to be rated exceptional, a claims examiner needs to hit a “production target” of 22 claims reviewed in an hour when handling emergency medical claims like the ones Ben Krause and Bob Ramsey submitted.

To meet that goal, examiners can spend, on average, less than three minutes reviewing each claim.

In those few minutes, claims examiners must make a series of determinations.  Is the cost covered by other insurance?  Was the veteran seen for a service connected issue?  Should the veteran have gone to a VA hospital instead?  Or should the case be sent to a nurse to review whether it was a true emergency?

Lagoe: “Do you have time to do that?”
Joe: “No.”
Lagoe: “Have you been doing that?
Joe: “No, and that’s the truth.”

In fact, Joe says that in order to meet the quotas, it’s quicker to simply deny claims than to take the multiple steps needed to approve them.

“You’re working with different programs too,” Joe said. “You’ve got two monitors, but you’ve got five programs that you have to look through to make that claim be payable. You don’t have the time.”

GAO’s 2014 warning

What Joe is describing mirrors the findings of a Government Accountability Office (GAO) report from 2014.

The GAO examined how VA staffers handled a slightly different category of emergency medical claims.

The report found that veterans were being “inappropriately denied” and being held “financially liable for emergency care that the VA should have covered.”

GAO also warned that the VA is at risk for inappropriately denying claims because “agency oversight activities do not focus on compliance with applicable requirements but rather on the timeliness of claims processing.”

Three years later, Joe says the same focus on speed over accuracy still exists.

“Are claims being denied unfairly because you and other claims examiners are not reading them thoroughly?” Lagoe asked.

“Yes,” Joe replied. “We were told to pick-n-click and get them moving.”

Denial by the numbers

KARE 11 wanted to know how often veterans are having their claims for emergency medical treatment denied.

We analyzed two and a half years of VA data and found in the VA MidWest Network, which includes Minnesota, 52% of all ER claims were denied.

As a result, $65,772,205 in medical bills were forced back onto veterans to pay.

There is no way to determine how many of those veterans got stuck with ER bills – like Ben and Bob – because of improper VA denials.

During a Congressional hearing last year, VA Assistant Deputy Undersecretary for Health for Community Care, Dr. Baligh Yehia submitted written testimony about veterans being denied payment for emergency room visits.

According to his testimony, in fiscal year 2014 “approximately 30 percent of the 2.9 million emergency treatment claims filed with VA were denied, amounting to $2.6 billion in billed charges that reverted to veterans.”

Why are there so many denials? This was Dr. Yehia’s explanation: “Since determination of these claims is nuanced, and unclear for veterans, there are a large number of denied claims.”

Remember, those nuanced claims are the same ones Joe said he and other examiners spend just minutes reviewing.

In Ben Krause’s case the Minneapolis VA blamed his original denial on a “coding error” by the non-VA emergency room that treated him.

Joe says that happens all the time.  Pressured to close out cases, he says examiners don’t take the time to make a few phone calls and try sort out what is often a minor communication error.

Instead, Joe says his office just mails out a denial letter.  That means veterans have to figure out the mistake on their own and begin an appeal process which can sometimes take years to work through the system.

“You get a claim and it’s not fully filled out or something is incorrect or anything like that, we just deny it,” he said.
Lagoe: “It’s not about being right for the veteran?”
Joe: “No, and that’s sad.”

“It really kind of tears at me that we look for the reasons, all of us, my teammates and I, everybody looks for the best reason to reject a claim,” Joe said. “Because that is the fastest way to get your numbers.”

The Minneapolis VA refused to respond to KARE 11’s questions, stating all questions needed to be directed to Department of Veterans Affairs headquarters in Washington D.C.

In a statement, Department of Veterans Affairs Press Secretary Curt Cashour denied the agency has quotas, writing “… staff who process claims have a performance plan that measures production standards, effectiveness, quality and customer service.”

VA has not responded to KARE 11’s repeated requests for copies of those production standards.

Regardless the label – quota or production standard – Joe and two other former VA claims examiners interviewed by KARE 11, maintain they are resulting in veterans being saddled with medical bills they should not owe.

Lagoe: “Sometimes what’s being denied, obviously should be approved?
Joe: “Yes.”
Lagoe: “That is a damning claim.”
Joe: “Yes.”


Our investigation started after a tip from a viewer.  If you have a suggestion, email us at:investigations@kare11.com


 

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