MINNEAPOLIS - Records show veterans in Minnesota continue to be stuck with emergency medical bills they should not owe despite a 2014 investigation by the Government Accountability Office (GAO) that documented similar improper denials by Department of Veterans Affairs.
“Was the expectation that this issue was being fixed?” KARE 11 Investigative Reporter A.J. Lagoe asked Randy Williamson, the GAO's lead investigator on the project.
“That was the expectation,” Williamson replied.
Beginning in June, KARE 11's continuing investigation – A Pattern of Denial – has documented how veterans are still being saddled with medical debt they should not owe, some of it even turned over to collection agencies after trips to the emergency room.
KARE's findings mirror what Williamson's GAO investigation discovered years ago.
A pattern of errors
“It was pretty much a pattern of a lot of errors,” Williamson told members of Congress during a 2014 hearing.
The GAO found the Department of Veterans Affairs was mishandling veteran's emergency medical bill claims, improperly denying claims that should have been approved.
“Some veterans were likely billed for care that VA should have paid for,” Williamson told members of the House Veterans Affairs Committee.
“We found that basically, VA was doing a very poor job,” Williamson recalls. “And they were erroneously denying claims.”
At the request of Congress, the GAO set out to determine how well the Department of Veterans Affairs was complying with the Federal Millennium Act which requires the VA, with a few exceptions, to cover the cost of emergency care for veterans at Non-VA hospitals.
Williamson and his team discovered repeated errors.
“Twenty percent of the cases we looked at were wrong, were denied inappropriately,” Williamson said.
“Is that an acceptable error rate?” Lagoe asked.
“Heavens no,” Williamson replied. “It's not.”
The GAO found that clerks were denying medical bills without a qualified clinician reviewing them. The investigation also documented cases in which the VA had given veterans pre-approval to go to an outside hospital, but later denied their claim as unauthorized.
That's exactly what KARE 11 found still happening to veterans like Bob Ramsey.
Bob called the VA to ask what he should do when experiencing post-surgical leg pain. He says he followed the instructions he was given to seek private emergency care. So, he expected no problems with his bill.
He was wrong. The Minneapolis Non-VA Care Department sent him a letter denying his claim.
“I called for advice, called to ask what they wanted me to do. They told me what to do. I did what they told me to do, and then they refused to pay,” Bob said.
Bob says 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.
Tired of fighting with the VA, and afraid the unpaid bill would hurt his credit, Bob says he paid the bill.
“I paid the bill because it was already in collections. I didn't want that hurting my credit any more than it already had,” he said.
The day after KARE 11 emailed the Minneapolis VA asking questions about Bob's case, the VA did a sudden about-face. A VA official left him a voicemail promising to immediately pay the bill they had previously denied.
Williamson said the GAO found denials like that were a systemic problem.
“One of the hospitals that they (VA) rated in their top 10 in the country, we visited and found numerous cases where improper denials had been made,” he recalled.
Speed before accuracy
Why was it happening?
The GAO report found VA management was only tracking how quickly claims were done. But management was not checking if they were done correctly.
“They looked at the timeliness of the claim processing, but they didn't look at the appropriateness of the denials,” Williamson told KARE 11.
“Nobody was checking?” Lagoe asked.
“Nobody was checking,” Williamson responded. “I would say that it is a case of people not being diligent in doing their jobs, not being thorough in doing their jobs.”
Despite the red flags, the GAO raised to both the Department of Veterans Affairs and Congress, VA insiders tell KARE 11 that little has changed. They say the focus remains on speed with little thought to accuracy.
A current VA employee turned whistleblower said improper ER bill denials continue to happen because medical claim processors are pressured to review complicated files in just minutes.
“Joe” spoke to KARE 11 on the condition that we do not use his last name.
“We are accountable for speed,” Joe said. “And the faster you are, the more your performance goes up - your review does, you get a bonus.”
To achieve an “exceptional” employee rating, Joe says 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?”
Lagoe: “Have you been doing that?
Joe: “No, and that's the truth.”
In fact, Joe says that to meet the performance goals, it's quicker to simply deny claims than to take the multiple steps needed to approve them.
While GAO did not specifically determine whether the VA's performance standards were causing veterans to be wrongfully denied, they did find what Williamson described as lax supervision and poor accountability.
The GAO also found the wrongful denials were prompting some veterans to take dangerous risks.
Fearing they might be stuck with an emergency bill the VA would not pay, veterans were by-passing the closest emergency room to drive miles to a VA facility.
“One veteran with a gunshot wound had his wife drive him to a Veterans hospital a hundred miles away, rather than go to the nearest facility in the community,” Williamson said.
“Why?” asked Lagoe.
“Because the veteran thought he would be on the hook for the bill and he didn't want to do that,” Williamson replied.
The GAO report made 12 recommendations, but Williamson told Congress back in 2014 he was concerned VA was not fully implementing them.
Three years later, KARE's investigation documented continuing problems – case after case of veterans still falling victim to the VA's pattern of improper denials.
“Based on what we know now, and based on some things I've heard from VA, it's not completely fixed,” Williamson said.
In response to KARE 11's reporting, a different government agency is beginning yet another review of VA's emergency medical claim processing.
Congressman Tim Walz (D-MN) asked the VA Inspector General to open an investigation.
The Inspector General recently informed the Congressman it has launched a nationwide inquiry.
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