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VA Fears Emergency Care Claims Could Open Floodgates

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By Debbie Gregory.

A recent ruling by the U.S. Court of Appeals for Veterans Claims to pay claims for emergency care reimbursements could open the financial floodgates and cost the VA over $10 billion.

The case, filed by Richard W. Staab, appealed a December 6, 2013, Board of Veterans’ Appeals decision that denied Staab reimbursement of medical expenses incurred for emergency medical services provided at non-VA medical facilities.

Some two million claims for emergency healthcare services that were provided to VA-enrolled veterans through the private sector could be eligible for VA reimbursement if the decision is allowed to stand.

The VA has until September 20th  to appeal the decision to the U.S. Court of Appeals for the Federal Circuit.

In the interim, VA officials say they are unable to begin to pay any of the emergency healthcare claims until they can prepare new regulations to support the complex review process.

In Staab’s case, the court agreed with lawyers for the 83-year Air Force veteran who was forced to pay $48,000 in healthcare costs following open-heart surgery in December 2010.

For a number of years, the VA has maintained that, by law, it can only reimburse VA-enrolled veterans for outside emergency care if they have no alternative health insurance. That includes Medicare, TRICARE, employer-provided health insurance or contracted health plans of any kind. Unfortunately for veterans with other health insurance, they are  often stuck paying hefty out-of-pocket costs that their plans won’t cover, while veterans with no other insurance see the VA routinely pick up their entire emergency care tab.

Effective in early 2010, Congress clarified the law on the VA coverage of outside emergency care. A single provision was changed to say the VA could “reimburse veterans for treatment in a non-VA facility if they have a third-party insurance that would pay a portion of the emergency care.”

The VA appears to be saying that the 2010 law was intended to allow the VA only to cover emergency costs not fully covered, for example, by the insurance of a driver at fault in an accident that injured a veteran. But to be eligible, the veteran still can’t have other health insurance.

The VA estimates that some 70 million claims could be eligible for reimbursement going back six years and forward for 10. The administrative costs alone could top $182 million over the next 10 years, raising total VA costs to $10.8 billion.

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