MINNEAPOLIS – Thousands of veterans every year are saddled with medical debt they shouldn’t owe – some of it even turned over to collection agencies – after trips to the emergency room.
A KARE 11 Investigation discovers it’s happening, in part, because the Department of Veterans Affairs does not consistently apply its own rules.
A Tough Night
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.
“It was a tough night, that’s for sure,” recalled Ben. It was the night he spent hours in a Woodbury, Minnesota emergency room.
“The idea of losing him, Ben, with a little baby here – it was really scary,” said Gretchen, fighting back tears.
Ben says he began experiencing severe chest pain and was struggling to catch his breath.
“I felt like my chest was about to pop,” he said.
“I remember he said, ‘Something’s wrong,’” said Gretchen. “Something’s wrong!”
Fearing her husband was having a heart attack, Gretchen grabbed the baby out of bed and drove the family to the emergency room at HealthEast’s Woodwinds Hospital. They spent the next nine hours there.
Doctors determined that instead of a heart attack, 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 expected the Minneapolis VA would automatically pick up the $6,066 hospital bill.
He was mistaken.
The Prudent Layperson Denial
“I got a letter in the mail saying they were going to deny me,” said Ben.
Ben’s case raises the question, just what does the VA believe is a prudent layperson’s definition of an emergency?
To find an answer, KARE 11 looked to the VA’s Prudent Layperson Fact Sheet.
The letter, which appears to be a boilerplate form, said Ben was being denied reimbursement for his visit to Woodwinds Health Campus because, “The treatment provided does not meet the Prudent Layperson definition of an emergency.”
“Apparently, a prudent normal guy wouldn’t have gone to the emergency room if they were experiencing chest pains,” exclaimed Ben sarcastically. “A normal layperson would have just sat on the couch, I guess.”
The Fact Sheet describes a prudent layperson as someone:
“… possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy.”
Gretchen Krause maintains she and her husband did what anyone would have done when facing a similar situation.
“I’m not a doctor, I’m not a nurse,” she explained. “I know when to go to the ER. You go to the ER when someone is in distress, and he was in distress!”
While many veterans might have concerns about challenging the VA denial, Ben Krause happens to be one of the nation’s most prominent and outspoken veteran’s rights attorneys.
Ben likens the VA’s letter to bad faith insurance denials. “This is straight out of the insurance company 101 books on how to deny a claimant,” he said.
In fact, KARE 11 discovered the VA’s own guidelines spell out an example of when a veteran was acting prudently when they visited an emergency room – even if the final diagnosis turns out to be something less serious.
“Case Example A” describes a patient who goes to the ER complaining of chest pain but is given a diagnosis of “mild gastric irritation.”
The VA’s “Prudent Layperson Fact Sheet” goes on to state that because chest pain is a “potentially serious problem” it “clearly falls into the category of what any prudent layperson would consider an appropriate use of an emergency department.”
“When you look at it this, it is almost verbatim your case,” KARE Investigative Reporter A.J. Lagoe said to Krause while reading the VA Fact Sheet.
“Right,” Krause laughed. “It’s black and white and it is Case Example A!”
“This is spot on exactly what I experienced,” Krause said. “Chest pains, going to the emergency room. I’m not a doctor! How am I going to know whether I’m truly having a heart attack or not?”
KARE 11 wanted to know, is Krause’s case an isolated problem, or a systemic pattern of dubious denials?
“If it happened to me, I guarantee it’s happening to thousands of veterans nationwide,” Krause said.
He is right.
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.
That statement shows between the beginning of fiscal year 2014 and August of 2015, approximately 98,000 claims were denied because the condition was determined not to be an emergency.
Dr. Yehia wrote, “Many of these denials are the result of inconsistent application of the ‘prudent layperson’ standard from claim to claim and confusion among Veterans about when they are eligible to receive emergency treatment through community care.”
He added, “When denied, the financial responsibility for these claims, which can be substantial, often falls on Veterans…”
“It’s absurd,” said Krause who wrote about his imprudent layperson denial on his popular veteran’s blog.
In his article, he served notice to the VA he was working with KARE 11 to get to the bottom of his claim denial.
The same day KARE 11 emailed the Minneapolis VA asking for an interview to discuss the case, Krause says he received a call from an official saying a mistake had been made and his claim should not have been denied.
“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.’”
Minneapolis VA officials refused to be interviewed for this report.
However, in an email they blamed the denial on a “coding error” by the non-VA emergency room that treated Krause. They also stated that at the time of the initial denial, VA did not yet have all his records.
It appears the denial letter was issued without anyone at the VA contacting either the private hospital or Krause to determine the nature and cause of his hospital visit.
The VA spokesman confirmed that Krause’s entire claim for emergency medical care is now being covered.
Even so, Krause questions how many other veterans have the ability to quickly get the VA’s attention without going through the appeals process, which often takes up to five years.
“If you don’t have the ability to get your story out there,” he said, “I mean, you’re not going to get the justice you need.”