Had VA Compensation and Pension Exam For Increases (Migraines, PTSD, Foot Pain, And Knees) Not Sure If It Went Well

So I went on Friday. Saw two examiners. I didn’t have time to submit my Statements in Support of Claims (PTSD & knees) my wife and adult children filled out, but I had them read them while I was there.  I just uploaded them on Monday.

The first was a Nurse Practitioner.

  • She checked my feet and knees. I don’t know if this was the smartest idea, but I didn’t wear my AFO or knee brace initially because I wanted her to see how I walk and move unassisted.  I put it on after her examination and showed her how I’m still not stable on that leg no matter which apparatus I’m using.
    • I explained my quality of life at work sucked because there’s only one elevator, which means I walk twice as far to use it. I work upstairs and have almost fallen several times.
    • I also told her I was concerned because the last rater wrote I was doing good with my orthotic insoles when I 100 percent told him that I can’t use the Navy-issued insoles for regular shoes. My feet rating was decreased because of that. So I made it clear verbally that I was not getting better.
  • For the Migraines increase, I showed her my migraine tracker chart, and she barely looked at it. It shows that I missed over 100 hours of work last year due to migraines.

The second was the Psychiatrist.

  • She didn’t ask me much about anything my VA psychologist wrote in her nexus letter.
  • She skimmed over my buddy statements.
  • She asked me about six questions, pretty much (yes or no) 
    • when was my last fight
    • about my job
    • am I taking my medications
    • have I been arrested
    • about my work history
    • about my sleep
  • It lasted about 15 minutes.

So who knows what is going to happen? All I know is I left there without any confidence that the evidence nor my exams helped.

We’ll see.

Read the Full Thread

VA DISABILITY EXAMS: Improved Performance Analysis and Training Oversight Needed for Contracted Exams

What GAO Found

The Veterans Benefits Administration (VBA) has limited information on whether contractors who conduct disability compensation medical exams are meeting the agency’s quality and timeliness targets. VBA contracted examiners have completed a growing number of exams in recent years (see figure). VBA uses completed exam reports to help determine if a veteran should receive disability benefits. VBA reported that the vast majority of contractors’ quality scores fell well below VBA’s target—92 percent of exam reports with no errors—for the first half of 2017. Since then, VBA has not completed all its quality reviews, but has hired more staff to do them. VBA officials acknowledged that VBA also does not have accurate information on contractor timeliness. VBA officials said the exam management system used until spring 2018 did not always retain the initial exam report completion date, which is used to calculate timeliness. In spring 2018, VBA implemented a new system designed to capture this information. GAO-19-13: Published: Oct 12, 2018. Publicly Released: Nov 8, 2018

VBA monitoring has addressed some problems with contractors, such as reassigning exams from contractors that did not have enough examiners to those that did. However, the issues GAO identified with VBA’s quality and timeliness information limit VBA’s ability to effectively oversee contractors. For example, VBA officials said they were unable to track the timeliness of exam reports sent back to contractors for corrections, which is needed to determine if VBA should reduce payment to a contractor. The new system implemented in spring 2018 tracks more detailed data on exam timeliness. However, VBA has not documented how it will ensure the data are accurate or how it will use the data to track the timeliness and billing of corrected exam reports. VBA also has no plans to use the new system to analyze performance data to identify trends or other program-wide issues. Without such plans, VBA may miss opportunities to improve contractor oversight and the program overall.

A third-party auditor verifies that contracted examiners have valid medical licenses, but VBA does not verify if examiners have completed training nor does it collect information to assess training effectiveness in preparing examiners. While VBA plans to improve monitoring of training, it has not documented plans for tracking or collecting information to assess training. These actions could help ensure that VBA contractors provide veterans with high-quality exams and help VBA determine if additional training is needed.

Why GAO Did This Study

In 2016, VBA awarded 12 contracts to five private firms for up to $6.8 billion lasting up to 5 years to conduct veterans’ disability medical exams. Both VBA contracted medical examiners and medical providers from the Veterans Health Administration perform these exams, with a growing number of exams being completed by contractors. Starting in 2017, VBA contracted examiners conducted about half of all exams. GAO was asked to review the performance and oversight of VBA’s disability medical exam contractors.
This report examines (1) what is known about the quality and timeliness of VBA contracted exams; (2) the extent to which VBA monitors contractors’ performance; and (3) how VBA ensures that its contractors provide qualified and well-trained examiners. GAO analyzed the most recent reliable data available on the quality and timeliness of exams (January 2017 to February 2018), reviewed VBA and selected contract documents and relevant federal laws and regulations, and interviewed agency officials, exam contractors, an audit firm that checks examiners’ licenses, and selected veterans service organizations.

What GAO Recommends

GAO recommends VBA (1) develop a plan for using its new data system to monitor contractors’ quality and timeliness performance, (2) analyze overall program performance, (3) verify that contracted examiners complete required training, and (4) collect information to assess the effectiveness of that training. The Department of Veterans Affairs agreed with GAO’s recommendations.
View Report (PDF)

694986

Unwarranted Medical Reexaminations for Disability Benefits VA OIG 17-04966-201

Why the OIG Did This Review

The OIG conducted this review to determine whether Veterans Benefits Administration (VBA) employees required disabled veterans to submit to unwarranted medical reexaminations.1
VBA employees have authority to request reexaminations for veterans “whenever VA determines there is a need to verify either the continued existence or the current severity of a disability,” and when there is no exclusion from reexamination.2 While reexaminations are important in the appropriate situation to ensure taxpayer dollars are appropriately spent, unwarranted reexaminations cause undue hardship for veterans. They also generate excessive work, resulting in significant costs and the diversion of VA personnel from veteran care and services.

What the Review Found

VBA employees did not consistently follow policy to request reexaminations only when necessary.3 The OIG team reviewed a statistical sample of 300 cases with reexaminations from March through August 2017 (review period) and found that employees requested unwarranted medical reexaminations in 111 cases. Based on this sample, the review team estimated that employees requested unwarranted reexaminations in 19,800 of the 53,500 cases during the review period (37 percent). VBA employees requested reexaminations for veterans whose cases qualified for exclusion from reexamination for one or more of the following reasons:

  • Over 55 years old at the time of the examination, and not otherwise warranted by unusual circumstances or regulation
  • Permanent disability and not likely to improve
  • Disability without substantial improvement over five years
  • Claims folders contained updated medical evidence sufficient to continue the current disability evaluation without additional examination
  • Overall combined evaluation of multiple disabilities would not change irrespective of the outcome of reexamining the particular condition
  • Disability evaluation of 10 percent or less
  • Disability evaluation at the minimum level for the condition4

The review team estimated that during the six-month review period, VBA spent $10.1 million on unwarranted reexaminations—$5.3 million involving Veterans Health Administration clinicians and $4.8 million involving VBA contractors.5 The review team estimated that VBA would waste $100.6 million on unwarranted reexaminations over the next five years unless it ensures that employees only request reexaminations when necessary.
In assessing the unnecessary burdens for veterans, the review team estimated that VBA required 19,800 veterans to report for unwarranted medical reexaminations during the review period. Reinforcing the needlessness of the reexaminations, approximately14,200 veterans experienced no change to their disability evaluations because of their reexamination. The review team estimated that the reexaminations resulted in proposed benefit reductions for about 3,700 veterans.6 At the conclusion of the review period, these proposed reductions remained subject to a final decision and an appeal process; therefore, the OIG did not make a determination on whether the reductions were justified.7 Unwarranted reexaminations also created unnecessary work for Veterans Affairs employees, which reduced VBA’s capacity to process benefits claims and the Veterans Health Administration’s (VHA’s) capacity to provide healthcare services.

Why This Occurred

Prior to requesting that a veteran appear for a medical reexamination, VBA policy requires a Rating Veterans Service Representative (RVSR) to review the veteran’s claims folder and determine whether the reexamination is needed (pre-exam review).8 The pre-exam review serves as an internal control to prevent unwarranted reexaminations. The review team estimated, however, that 15,500 of 19,800 unwarranted reexaminations (78 percent) lacked a pre-exam review by an RVSR, indicating that VBA management routinely bypassed this internal control. Instead, VA Regional Office (VARO) managers routed these cases directly to a Veterans Service Representative (VSR) for scheduling the reexamination.
VARO managers explained that routing cases directly to VSRs was consistent with guidance from the Executive in Charge for VBA. The guidance recommends that tasks not directly related to making a disability rating decision should not be assigned to an RVSR. The Executive in Charge confirmed that the VARO managers’ interpretation was consistent with his expectations. He explained to the review team that RVSR capacity is limited, and therefore an RVSR should not spend time on activities that do not directly relate to making rating determinations. Reinforcing the Executive in Charge’s mandate, VBA redesigned its employee performance standards in 2017. This revision resulted in RVSRs earning work credit for rating decisions but not for other transactions, such as canceling an unwarranted reexamination.
Bypassing the pre-exam review caused unwarranted reexaminations. VARO managers routed the work to VSRs who lacked the training and experience necessary to make accurate determinations about whether a reexamination was warranted. Determining whether a reexamination is necessary is an RVSR responsibility; however, VSRs were tasked with making this determination. VBA employees and managers stated that determining the necessity of a reexamination requires specialized knowledge, including the ability to review medical evidence. Similarly, 14 of the 24 VSRs interviewed told the review team that they were unfamiliar with the criteria for determining whether a reexamination was necessary.
VBA also did not invest in developing alternative internal controls to compensate for the lack of a pre-exam review. VBA could add features to the Veterans Benefits Management System (VBMS) to prevent the scheduling of reexaminations in cases that meet the exemption criteria, such as information system automation. VBA has not implemented these features in VBMS due to reported competing technology priorities and a lack of funding. In September 2017, VBA took initial steps and implemented a technology strategy designed to reduce unnecessary work by identifying and canceling work items for veterans age 55 or older that would have resulted in unwarranted reexaminations. This effort resulted in the one-time elimination of approximately 45,000 reexaminations. VBA plans to implement additional one-time cancellations in the future, and VBMS automation is scheduled for FY 2019 or later.
Finally, VBA’s quality assurance processes did not measure whether VBA employees requested reexaminations only when necessary, nor did these processes evaluate whether an RVSR conducted a pre-exam review as required by VBA policy.

What the OIG Recommended

The OIG made four recommendations to the Under Secretary for Benefits:

  • Establish internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modify VBA procedures as appropriate to reflect these improved business processes.
  • Take steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.
  • Enhance VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and to categorize unwarranted reexaminations as errors.
  • Conduct a special focused quality improvement review of cases with unwarranted reexaminations to understand and redress the causes of any avoidable errors.

Management Comments

The Under Secretary for Benefits concurred with three of the four recommendations, and concurred in principle with the fourth recommendation. The Under Secretary for Benefits provided acceptable action plans for all four recommendations. The OIG will monitor VBA’s progress and follow up on implementation of the recommendations until all proposed actions are completed.
The Under Secretary for Benefits also provided technical comments related to this report. The OIG considered those comments and made clarifications where applicable.

1 VBA also refers to medical reexaminations as routine future examinations.

2 38 CFR §3.327, Reexaminations.

3 The relevant policy is found in M21-1 Adjudication Procedures Manual, Part III, Subpart iv, Chapter 3, Section B, Topic 2, Determining the Need for Review Examinations.

4 VBA relies on these objective criteria to identify disabilities that are unlikely to improve and therefore do not merit the expense and burden of reexamination.

5 The review team estimated the cost of unwarranted reexaminations using the results of the team’s statistical sample claims review. See Appendix C for more information on the statistical sampling methodology and results.

6 The review team did not project cost savings based on the 3,700 veterans with proposed reductions because the reductions were only proposals—not final reductions. When VBA makes a final decision, the proposed reduction amount may be changed, or there may be no reduction at all.

7 The review team estimated the number of veterans who had proposed benefits reductions using the results of the team’s statistical sample. Some reexaminations resulted in increases to veterans’ benefits, but the small sample size prevented the review team from making a statistical projection to estimate the value of all increases during the review period.

8 M21-1 Adjudication Procedures Manual, Part III, Subpart iv, Chapter 3, Section C, Topic 2, Control of Future Examinations. For this report, the OIG defines the required RVSR review prior to a reexamination request as the Pre-exam Review.

[pdf-embedder url=”https://hadit.com/wp-content/uploads/2018/07/unwarranted-medical-reexaminations-for-disability-benefits-VAOIG-17-04966-201.pdf”]

Musculoskeletal VA Disability Claims – Sharp v Shulkin May Make Higher Disability Percentage Ratings Possible

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USCAVC Sharp v. Shulkin No. 16-1385 Mr. Sharp, an Army Korean War veteran who suffers from numerous musculoskeletal injuries, argued that Veterans Affairs medical examinations he received were inadequate because the examiner failed to “ascertain adequate information — i.e., frequency, duration, characteristics, severity, or functional loss — regarding his flares by alternative means,” according to court documents. Mr. Sharp contended that the 10% disability rating he received for his injuries was therefore insufficient because his “September 2015 evaluation was inadequate for evaluation purposes and the Board’s finding to the contrary was clearly erroneous.” In September 2017, the claims court agreed.

The Sharp case clarifies the responsibilities of the C and P examiners and the BVA in giving opinions on pain flare-ups in musculoskeletal disabilities claims. The court ruled the current system was inadequate.

Read the full article below:
https://taskandpurpose.com/vets-may-now-able-get-higher-disability-ratings-service-connected-injuries/

Title 38: Pensions, Bonuses, and Veterans’ Relief PART 4—SCHEDULE FOR RATING DISABILITIES  Subpart B—Disability Ratings

The Musculoskeletal System
§4.40   Functional loss.
Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like.
§4.41   History of injury.
In considering the residuals of injury, it is essential to trace the medical-industrial history of the disabled person from the original injury, considering the nature of the injury and the attendant circumstances, and the requirements for, and the effect of, treatment over past periods, and the course of the recovery to date. The duration of the initial, and any subsequent, period of total incapacity, especially periods reflecting delayed union, inflammation, swelling, drainage, or operative intervention, should be given close attention. This consideration, or the absence of clear cut evidence of injury, may result in classifying the disability as not of traumatic origin, either reflecting congenital or developmental etiology, or the effects of healed disease.
§4.42   Complete medical examination of injury cases.
The importance of complete medical examination of injury cases at the time of first medical examination by the Department of Veterans Affairs cannot be overemphasized. When possible, this should include complete neurological and psychiatric examination, and other special examinations indicated by the physical condition, in addition to the required general and orthopedic or surgical examinations. When complete examinations are not conducted covering all systems of the body affected by disease or injury, it is impossible to visualize the nature and extent of the service connected disability. Incomplete examination is a common cause of incorrect diagnosis, especially in the neurological and psychiatric fields, and frequently leaves the Department of Veterans Affairs in doubt as to the presence or absence of disabling conditions at the time of the examination.

eCFR

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Back and Cervical Pain – Bulging Disc and the C and P Exam ROM Test – Hadit.com For Veterans Who’ve Had it With The VA

I have a C&P coming up in October for Neck/Back pains. While in Iraq in 2004, I fell off of a 916 semi-truck and have buddy statements to verify this.


 

Read more about Musculoskeletal VA Disability Claims

site:hadit.com Musculoskeletal + “flare up” – Google Search

Jun 11, 2017 … If the examination is not being conducted during a flare- up: [ ] The examination is medically consistent with ….. wears brace when he leaves the …

10 Tips to Help You Keep the VA C and P Exam in Perspective

C and P Exam Definition Source: CCK-Law.com

A C and P exam, is a medical examination of a veteran’s disability, performed by a VA healthcare provider, or a VA contracted provider.  VA uses C&P exams to gather more evidence on a veteran’s claimed condition before issuing a decision and assigning a rating.  Most commonly, C&P exams are used to (1) confirm or deny service connection, and/or (2) establish the severity of a veteran’s disability.  Before the exam, the examiner will review your entire claims file, which contains previously submitted evidence and medical treatment records.  The exam itself usually only lasts about 15-20 minutes but can range anywhere from 5 minutes to several hours.

During the C&P exam, the examiners will ask questions about your disability and how it affects aspects of daily functioning.  VA examiners might complete a Disability Benefits Questionnaire (DBQ) as well.  Each DBQ is drafted to correspond with a specific condition and is formatted for examiners to “check a box” next to descriptions that most accurately depict the disability in question.  After the exam, the examiner will write up a report that includes a review of the exam’s findings, any clinical test results, and any medical literature used by the examiner.  The C&P exam is then added to your claims file as part of the evidence VA adjudicators will use to make a decision.

What is that Perspective?

Honestly, it comes down to recognizing that the purpose of the VA C and P Exam is NOT to convince the doctor that your injury is service-connected but to let them conduct their exam and draw their conclusion. Ultimately, your current disability is or is not related to military service. Regardless of what the doctor says or what the VA Rater says, the limitations or symptoms are either related or not to your time in service.” Chris Attig Veterans Law Blog

A doctor’s opinion can’t change what is or is not. It’s just another piece in the puzzle of proof. And the C&P Exam is just another piece of that puzzle. It is not the only piece – but if we view it as such, we often make our claims harder than they should be. And we certainly make them more stressful.

Reprinted here with permission from Veterans Law Blog

1. Every C&P Exam has 2 Goals.

The first goal is to have the doctor confirm that your injury, disability, or

limitations are related to your military service – to prove the Nexus Pillar – and/or

to establish the degree you are disabled – the Impairment Pillar

Caluza Triangle

The second goal is to draw out the “evidentiary gap” in your claim through a C&P exam. The evidentiary gap is the difference between what is IN the record and how the VA SEES what is in the record. If you are denied service connection, it is almost always because of an evidentiary gap. Rather than throwing a haystack at the RO and then yelling at the VA for not finding the needle – let the Examiner tell you what is missing by reading their opinion.

The key is NOT to provide excessive amounts of information in your C&P exam – keep your answers short and “make” the doctor get into your file to review the evidence. They tell you what is missing by what they focus hardest on. It is THEIR report which shows the evidentiary gap – not your statements in the C&P. This brings us to the next tip….

2. Answer only the questions the VA C and P examiner asks.

If the doc asks, “How are you doing,” and you throw the entire history of your claim at her over the next 15 minutes, what happens? She zones out. She doesn’t hear what you are saying and may find it hard to care about it. I get emails daily – some are 8-9 pages of micro-detailed histories of a VA Claim. It’s hard to read them. It’s hard to understand them. It’s hard to pick up the phone and call that person because I know I will get more facts I don’t need. Listen, I’m really good at doing this work, and while there are some real shit-bird doctors out there, there are some really good ones. They know how to call out the information they need to get the facts to understand the situation. So just answer the question you are asked – not the question you want to answer. But when you do answer the question, follow Tip #3

3. Keep it Simple and Basic.

Limit what you say to symptoms and limitations or nexus to brief statements. If you can’t answer the question “Why is your injury related to military service” in under 20 seconds, you are talking too much. Here’s a great example of how you might respond to a VA C&P Examiner’s question about nexus: “You should defer to my Claims File as that has my complete position on why my injury is related to my service….but, very generally…..  Because of the in-service injury to my right knee, I began to overcompensate. Now my left knee needs replacement.” or “I was raped in basic training, and during the rape, my attacker broke my jaw. I now cannot eat or swallow properly.” or “I was diagnosed with prostate cancer while in service.” The more you talk, the more ways an examiner has to deny your claim without ever looking at the file. The less you talk – the more direct and to the point you are – the more they have to read the file.

4. Be Polite and Courteous – and Know What the Examiner has to Deal With.

I’ve said it before – there are some real shit-bird docs in the VA system. There’s the examiner that comes into the room – grumbly and angry – and tells you that you have five minutes to tell your story. There’s the examiner that will hear something different than what you said – and twist your words to fit their medical theory. And there are the examiners that just plain don’t get it – they may not have the medical training needed to draw the conclusion they are being asked to draw. Even if you are a VA C&P Examiner reading this, I think you would agree that you can think of a colleague who is not doing what they are required to do.

Smile. Be pleasant and courteous. Know that even if this VA C and P Examiner concludes that there is no nexus between your military service and your condition, it will not be the end of the world.

Smile. Be pleasant and courteous. Know that even if this doctor concludes that there is no nexus between your military service and your condition, it will not be the end of the world. There are ways to “correct” a bad C&P Exam

Your C&P Examiner has a short time to talk to you. They will have 15-20 (or more) exams daily. Each exam will be for a Veteran with at least 750+ pages of records to comb through. These examiners have something in common – they work in an overburdened system that overloads them with information and gives them minutes to sort through it. Sometimes they will have to draw conclusions about complex conditions they are not trained to handle. And a good bit of the time, they will make mistakes. They will get it wrong.

It’s not the end of the world if they do. But what is essential – in the grand scheme of fixing this system – is that we treat every C&P Examiner with a modicum of courtesy and respect. Say hello. Smile. Be pleasant and courteous. Know that even if this doctor concludes that there is no nexus between your military service and your condition, it will not be the end of the world. There are ways to “correct” a bad C&P Exam. There are other types of opinions that you can use – like the Disability Benefits Questionnaire (DBQ).

Get their name, and talk to them about their background – and after the exam, write down thorough notes about what happened – good and bad – in the exam.  What did they test? What did they measure? What body parts did the doctor look at – and not look at.

Suppose you are going to legally attack a bad C&P Exam. In that case, you will need this information to challenge the methodology, measurements, and conclusions. And you won’t be able to do this if you start the exam on a sour note. So – above all – be courteous, civil, and concise.

5. Don’t Act Like a “Professional Claimant”. 

C&P Examiners do exams – dozens a day – every day for weeks on end. When you are exposed to this many Veterans, you start seeing patterns. Especially if you are a doctor trained to identify and analyze patterns of symptoms and limitations in a medical condition.

  • Listen, C&P Examiners can spot the Professional Claimant a mile away. And if they see you as a Professional Claimant, it will taint the exam and the outcome of the exam.
  • So resist using legalistic phrases, theories, and concepts.
  • Talk like a human being – not a lawyer or a VSO.
  • Tell the doctor about your symptoms. Your limitations.

Have a concise statement of why you think your disability and service are related. (Take a look at the first post in this series to get an example of how to put together such a concise statement).

And whatever you do, don’t go off on rants about the VA Process, complex legal theories, or past errors.

The system is screwed up – we all get that. But one VA C&P Examiner isn’t going to fix the whole system or remedy every past error in your case.

So keep it simple and basic: talk only about the symptoms and limitations of your disability, and have a one-sentence statement about nexus to tell the doctor when you are asked.

6. Do NOT Advocate – or Debate With – at your VA C and P Exam.

C&P Examiners are doctors – not lawyers and not judges. 

Don't Argue - at your VA C and P Exam Most Veterans that try to prove their claim end up overwhelming the VA C and P Examiner with facts they may or may not be able to process at the moment. They will overload them .
Don’t argue with the examiner.

Don’t argue.

Though their opinion will carry some sway – a lot of sway – with the Rater in your claim, in the end, it is just an opinion.

Let them draw their opinion. If it is negative or doesn’t fit the facts, there are other doctors with other views that the Rater or BVA can balance and weigh to find the truth.

Do NOT try to prove your claim to the examiner. Most Veterans that try to prove their claim end up overwhelming the C&P Examiner with facts they may or may not be able to process at the moment. They will overload them with case law and legal language – much of which is irrelevant to the Doctor.

And remember – there is a mortal battle between doctors and lawyers. Since the first lawyer sued the first Doctor, they have always had a very cat-and-dog relationship (I say this somewhat “tongue in cheek”). If you start talking like a lawyer, you will shut that Doctor off from understanding your medical condition. I can guarantee that your Exam will end with a negative opinion.

Think about it in the context of your most recent job or profession – if someone walked in and started barking all this legalese while telling you how to do your job, what would your reaction be?

You’d feel bullied or attacked. You’d feel insulted and marginalized. You might zone out on the person talking and miss what they are trying to say. Or you might do whatever you had to to get that person out of your office, cubicle, or maintenance bay.

Nobody likes being bullied. So don’t advocate your claim to the C&P Examiner – it’s not the time and place to advocate for your claim.

It is the time to talk about symptoms and limitations – and to DRIVE the examiner back into your C-File and medical records to study the claim.

Rather than launch into the medical and legal theory of your claim, and spend 15 minutes forcing the C&P Examiner to “zone out,” why not push them to look at the records.

Consider this exchange:

Doctor: Tell me about your sleep apnea symptoms since you left the military.

Veteran: My medical records and claims file detail all of the symptoms – the many apneas throughout the night, my need for a CPAP, the daytime sleepiness problems from getting a good night’s sleep – but the bottom line is that since service, I wake up several times each night gasping for air, and the only relief I get is when I wear this CPAP machine.

You got your point across – succinctly. You pushed the examiner to look at the facts (if she doesn’t, that will be obvious in her decision). And you did it concisely and courteously.

The bottom line – the C&P Exam is not the time to be an advocate or a lawyer.

Keep your discussion limited to symptoms and limitations only, and your one-liner about why you think it is service-connected.

The bottom line – the C&P Exam is not the time to be an advocate or a lawyer.

Keep your discussion limited to symptoms and limitations only, and your one-liner about why you think it is service-connected.

7. Know What is “At Issue” in the VA C and P Exam.

In earlier tips, I told you to talk only about symptoms and limitations. If you have to, have a brief statement (20 seconds and 1 sentence) that explains why you think your condition is service-connected. But this begs the question – how do you know what will be discussed in your C&P exam? This comes back to understanding the 4 Pillars of a VA claim. 

Your C&P exam will invariably involve issues in only 2 of those pillars:

You can read about all 4 Pillars by clicking here


As you read the sample format below, think whether this kind of organization might help a VA Rater more easily understand your claim and – at least in my experience – empowers THEM  to issue a quicker decision for YOU.

A. CONDITION: DIABETES.
Pillar 1:  Eligibility as a Veteran
I have shown that I am an eligible Veteran. Explain the details of how you became eligible, and cite to the page in your VA C-File that has the evidence PROVING that you are eligible.

Pillar 2:  Service Connection
I have shown that I am entitled to service-connection of my diabetes because I showed evidence of my high blood sugar in service, have provided a medical statement from the VA Medical Center showing that I have was diagnosed with Diabetes after my discharge, and have an expert medical opinion explaining how my Diabetes is at least as likely as not related to my military service.

Again, be sure to cite to the page in your VA C-File that has the evidence PROVING that you are eligible.  It doesn’t matter whether you THINK you have proven service-connection. What does matter is that you provide EVIDENCE that you did prove each element.

Pillar 3: Impairment Rating.
I have attached a DBQ (Disability Benefits Questionnaire) from my VA Medical Center Doctor that shows the current state of my diabetes, and in comparison with 38 CFR Table 4 (Diagnostic Code 7913) I believe I am entitled to a 40% rating for my Diabetes.

Pillar 4: Effective Date.
It is my opinion that I am entitled to an effective date of [Choose the earliest date you think the law will support]. However, I will reserve my arguments about effective dates until after the VA Ratings Decision granting service-connection and a 40% Impairment Rating is issued.

Suppose your exam is for a condition that has not been service-connected. In that case, it is a good chance that it is either a “nexus” or a “diagnostic exam.”

Let’s talk about the diagnostic exam. Remember that the VA has a Duty to Assist?

While I always tell Veterans not to confuse the “Duty to Assist” with “Actual Assistance,.” There is one scenario where I think the VA does a good job of assisting Veterans in their claims.

That scenario arises if you have not yet had your medical condition diagnosed – in certain situations, the VA is required to send you for a Diagnostic Exam to diagnose your medical condition before a decision can be made about service connection or impairment rating. If, however, there is no reasonable possibility that the condition could be service-connected even if diagnosed, the VA does NOT have to send you for a Diagnostic Exam.

Suppose your exam is not a diagnostic exam. In that case, you can be sure that the doctor will want to talk to you about “nexus” and the “impairment rating” criteria.

So here’s what you should do – first, prepare your brief statement as to why you think your condition is related to military service – keep it short and sweet (see Post #1 for a great example) and remember that the goal is to force the Examiner into the C-File to study your medical and military service records.

Next, look up the rating criteria in 38 CFR Table 4 to determine what factors the doctor will want to know when deciding on your rating percentage.

Click here to learn how to find out what your Impairment Rating criteria are. Focus on these symptoms and limitations in your discussion.

Lastly, if you have enough time before your exam, prepare a summary of your medical records for the doctor to review – even if they already have the C-File.

I explain exactly how to do this in my Training package – How to File a VA Claim.

In that video, I will teach you how to assemble and organize the medical evidence that proves your claim for service connection by using my unique “VA Claim Map.“

It’s not hard to do, and it will help you keep your claim organized. Many doctors have really appreciated the summary of the claim that we sometimes send with our clients to C&P Exams.

8. If you talk about your condition, paint a picture.

When I tell my clients this tip, I tell them to think of “Toilet Bowls.” I had a client going in for a C&P Exam to re-evaluate the impairment rating on his knee condition. The prior VA Examiners had never considered the “instability” in his knee joint when low-balling his rating in the past. So we knew this exam would focus on the instability of the Veteran’s knee.

In our prep for the C&P exam, I asked my client to describe his knee instability. Here’s the story he told me.

“When I use the restroom at work, I cannot get off the toilet bowl without help. I tried but broke the toilet paper rack because it could not support my weight without breaking. I was lying on the floor in my own piss while my co-workers helped me stand up and get my pants on. I have this problem at home and in public restrooms everywhere – I cannot stand up off the toilet on my own because my knee is so weak and unstable.” 

That story is particularly effective in describing problems with knee stability. Why? Because the Veteran painted a picture that used a toilet bowl – and nobody can forget those visual images.

Now, I’m not saying to describe all your symptoms using a “Toilet Bowl” example. I am saying that you should paint a picture for the examiner of how the symptoms affect your daily life and work activities.

In a claim for aid & attendance, don’t say: “I need help getting dressed.” Instead, say: “My 16-year-old daughter has to help me zip my pants every morning because my Parkinson’s prevents my fingers from being able to work my own zipper.”

In a claim for PTSD rating, don’t say: “I have trouble getting along with co-workers.” Paint the picture, and say: “I spend 2 hours a day hiding in the bathroom at work on the floor of the accessible stall because I’m so scared of being around other people with my PTSD.” That’s not a picture – it’s just a statement that every other Veteran is probably telling the same examiner.

See what I’m saying?

Don’t state symptoms. Paint a picture.

But be careful – don’t embellish…everyone can spot someone engaging in self-serving hyperbole or exaggeration (you know the type – in the military, we called them “Bulls**t Artists”).

Just describe the problems your symptoms are giving you in your daily living and working activities by painting a picture of when and how often they surface.

9. Get the VA C and P Examiners name and a Copy of your C&P Exam.

I’ve shared this tip before – when the exam is done, ask the doctor for their business card or name if you can. Be friendly about it – not confrontational.

Why do you want to do this? Because the Veterans Court has said that unless you challenge a doctor’s credentials, you are allowing the VA to presume that the doctor was competent and the exam was adequate. So, get the doc’s name. Then read up on how to challenge the doctor’s credentials in a Notice of Disagreement if your C&P Exam returns adverse.

And then – I cannot stress this enough – get a copy of the C&P Exam. Before the Ratings Decision comes out if you can. Here’s how to get a copy of the C&P exam using the Freedom of Information Act (FOIA).

10. After the Exam – Write Down your Notes.

Take good notes during and after the VA C and P exam.

Take good notes at your C and P exam or regular VA appointment.

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