VA Claims: Disabled Veterans Community|

21st Anniversary Veteran to Veteran Podcast Veteran to Veteran 21st Anniversary. Tbird, founder of will be the guest and talk about the history of and will take calls from veterans.

A little history … Veteran to Veteran the website domain registered Jan 20, 1997.  The domain is registered and paid for thru Jan 21, 2023 at which time I plan to register it for another 15 years, Lord willing and the creek don’t rise.
I guess the best place to start is Jan 1991; I had gotten out of the navy Dec 1990. At my separation seminar, there was a DAV rep Jim Milton who told us to bring our medical records in and he would look through them for us and let us know if we should file a claim with Veterans Affairs.
Well, bless his heart, he opened my medical file, read the first insert, looked me straight in the eye, and said, “You will be 50% for the rest of your life” and that he would file the claim for me. 50% was for surgery I had in the service. True to his word, he met with me and talked with me for a long time, filled out my paper work and urged me to file for PTSD. I would not file the PTSD claim, nor even discuss it. I didn’t even understand what PTSD was then.
By Feb 1991 I had moved to the San Francisco bay area and was staying at a friend’s apartment and pretty much was just a puddle. In desperation one night I called the suicide hotline. I had no job, no idea about going to the VA. They talked with me for a long time and explained to me that I could go to the local VA hospital even if I did not have insurance. Now I know what you are thinking, if I was 50% why didn’t I just go to the VA in the first place? Two reasons, 1st, this was Feb 1991 and the 50% didn’t come till May and secondly, even if it had come thru it is unlikely that I would have had the mental acuity at the time to put the two together.
I relay this here because it is where so many of our brothers and sisters are coming from, perhaps where you started. Fuzzy and unsure, in pain and sometimes homeless they come to the VA hospital for help. And that is where I ended up. Up to the pysch ward I went, blah, blah, blah, a few days later I was released with a promise of a call from the out-patient program, which I would soon be entering. Blah, blah, blah, after many miscommunications, and no call backs, I was at the Day Hospital everyday M-F. And this brothers and sisters is where I began to learn and formulate my plan for
Veterans, veterans everywhere…I spent a year in the day hospital and about another year at a sheltered workshop before I got back on my feet. So I just talked to veterans everyday, waiting for appointments, waiting for prescriptions, waiting for a vet rep and I started to learn about the system.
While in the navy, I was a data analyst. I had to learn a 5 volume manual and just about anything you were suppose to do was in that manual. So I figured there must be a manual on how to do a VA claim or at the very least, regulations. So I found out about the Code of Federal Regulations, United States Code, Veterans Affairs Manuals and so on and so forth. Of course this was 1991/1992, I was living in a tiny studio apartment in a particularly bad neighborhood, working in a sheltered workshop where I earned a nickel per envelope I stuffed, throw in PTSD and you will see that it was a difficult task for me to get somewhere where they had copies of these, let alone that they would let me look at them. There was so much knowledge around me, it was
like the gold rush in those days. I could just sit on a bench where a veteran would sit down next to me, a little conversation later I had another nugget. I made copious notes. Phone numbers to call, ask for this guy or that guy, he’ll give you the straight scoop and they’d slip me a piece of paper with a number on it. You want to read this regulation or that one and another slip of paper into my hand. I spent a lot of time on those benches watching the squirrels as they gathered their nuts and I gathered mine 🙂
So I’m thinking I could put a little handbook together, print it out and hand it out at the VA. Or perhaps flyers. Still formulating, time goes by, 1994/1995 I am being treated for PTSD regularly and doing and feeling much better. I go to work for a company as a marketing systems analyst and I discover the internet. Well let me tell you, that was perhaps one of the most significant life changing events I have ever experienced. And I might add finally a positive one 🙂 It seemed only natural to me that surely there must be a website that contained all the knowledge I wanted. As it turned out,not so much. Lots of stuff, but I wanted to get straight to the claims information and there was a lot of stuff to wade through to get to it. So taking my lesson from the squirrels earlier I started to gather, gather, gather.  I learned html and worked as a marketing systems analyst and worked on my claim. 1996/1997 a major ptsd cork blows and unemployment follows. Working my claim, working the website. January 20th, 1997 I register the domain name right after getting off the phone with the Veterans Affairs and saying, “I’ve had it with this”.  As fate would have it, the old DAV board went down just as mine opened up and folks start to wander in.
So has two main components, the website and the the discussion board with links, articles, research resources etc. that support it.  The website starts to grow, I can’t tell you how many times I had to switch servers for space and features.  Emotionally I continue on a downward trend and in 1998 ended up back home in St Louis living in my sisters basement in therapy and working hard on pulling myself back up. The website continued to do great during this time, I just stayed in the basement, bought new software, new books, and learned how to make things work and I continued to use this knowledge to make better.
My 100% finally came through from the Veterans Affairs.  I have a friend Patrick Heavy who is an advocate who helped me thru my SSDI claim. He was literally at my side through the entire process. For him I am grateful. My therapist and sister continued to try to get me to leave the basement, but to no avail. At some point in 1998 or 1999 I put a counter on the website and was shocked to discover how many visitors we were getting. Time goes by, my sister gets married and I move from the basement to the upstairs. There is much celebration that Aunt T is living in the light again. More time goes by and I settle into my life in St Louis and spend more time on the site trying new things and finding more information. 2003 I bought my own home with my VA loan. For years now I have just considered my purpose in life. And so goes the story of the conception and birth of At 21 years old, she is established and going strong, I couldn’t be more pleased or proud. Thank you to everyone who has supported her growth.

VA failed to report 90% of potentially dangerous medical providers, GAO confirms


We aren’t asking for state of the art care, we are asking for quality competent care.

History doesn’t repeat but it often rhymes, how many times must our service be so devalued. Do we not deserve to receive the quality care we were promised, is the nations word no good to it’s own veterans. That should not be a stretch, it shouldn’t be that hard.

GAO found VA officials slow to investigate performance concerns of certain doctors. In 8 of 9 cases, VA failed to report docs who did not meet health care standards.

Highlights from the article

  • VA fails to report 90% of poor performing docs to national and state databases.
  • VA slow to investigate performance concerns.
  • VA failed to report docs who didn’t meet healthcare standards.
  • Concerns ranged from unsafe or inconsistent practices to incorrectly recording patient visits.
  • In one case a doc who had resigned while under investigation wasn’t reported and later hired by a non-VA hospital, not that surprising the doc was disciplined for the same conduct 2 years later at his/her new job.

Read the whole story be informed and outraged and share it with veterans. I’ve included the GAO report below the article link.


Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns GAO-18-63: Published: Nov 15, 2017. Publicly Released: Nov 27, 2017.

Fast Facts

The Department of Veterans Affairs requires its medical centers to review a doctor’s care if quality or safety concerns arise. If VA medical center officials decide a doctor should no longer provide care to veterans, they are required to inform hospitals and other health care entities by reporting to a national database and to the states where the doctor is licensed.

However, at the 5 VA medical centers we reviewed, we found that these reviews were not always timely. We also found that VA officials did not report 8 of the 9 doctors who should have been reported.

GAO recommends Veterans Affairs improve oversight of clinical care reviews and reporting.


What GAO Found

Department of Veterans Affairs (VA) medical center (VAMC) officials are responsible for reviewing the clinical care delivered by their privileged providers—physicians and dentists who are approved to independently perform specific services—after concerns are raised. The five VAMCs GAO selected for review collectively required review of 148 providers from October 2013 through March 2017 after concerns were raised about their clinical care. GAO found that these reviews were not always documented or conducted in a timely manner. GAO identified these providers by reviewing meeting minutes from the committee responsible for requiring these types of reviews at the respective VAMCs, and through interviews with VAMC officials. The selected VAMCs were unable to provide documentation of these reviews for almost half of the 148 providers. Additionally, the VAMCs did not start the reviews of 16 providers for 3 months to multiple years after the concerns were identified. GAO found that VHA policies do not require documentation of all types of clinical care reviews and do not establish timeliness requirements. GAO also found that the Veterans Health Administration (VHA) does not adequately oversee these reviews at VAMCs through its Veterans Integrated Service Networks (VISN), which are responsible for overseeing the VAMCs. Without documentation and timely reviews of providers’ clinical care, VAMC officials may lack information needed to reasonably ensure that VA providers are competent to provide safe, high quality care to veterans and to make appropriate decisions about these providers’ privileges.
GAO also found that from October 2013 through March 2017, the five selected VAMCs did not report most of the providers who should have been reported to the National Practitioner Data Bank (NPDB) or state licensing boards (SLB) in accordance with VHA policy. The NPDB is an electronic repository for critical information about the professional conduct and competence of providers. GAO found that

  • selected VAMCs did not report to the NPDB eight of nine providers who had adverse privileging actions taken against them or who resigned during an investigation related to professional competence or conduct, as required by VHA policy, and
  • none of these nine providers had been reported to SLBs.

GAO found that officials at the selected VAMCs misinterpreted or were not aware of VHA policies and guidance related to NPDB and SLB reporting processes resulting in providers not being reported. GAO also found that VHA and the VISNs do not conduct adequate oversight of NPDB and SLB reporting practices and cannot reasonably ensure appropriate reporting of providers. As a result, VHA’s ability to provide safe, high quality care to veterans is hindered because other VAMCs, as well as non-VA health care entities, will be unaware of serious concerns raised about a provider’s care. For example, GAO found that after one VAMC failed to report to the NPDB or SLBs a provider who resigned to avoid an adverse privileging action, a non-VA hospital in the same city took an adverse privileging action against that same provider for the same reason 2 years later.

Why GAO Did This Study

Nearly 40,000 providers hold privileges in VHA’s 170 VAMCs. VAMCs must identify and review any concerns that arise about the clinical care their providers deliver. Depending on the findings from the review, VAMC officials may take an adverse privileging action against a provider that either limits the care a provider is allowed to deliver at the VAMC or prevents the provider from delivering care altogether.
GAO was asked to review VHA processes for reviewing concerns about providers’ clinical care. This report examines, among other things, selected VAMCs’ (1) reviews of providers’ clinical care after concerns are raised and VHA’s oversight of these reviews, and (2) VAMCs’ reporting of providers to the NPDB and SLBs and VHA’s oversight of reporting. GAO visited a non-generalizable selection of five VAMCs selected for the complexity of services offered and variation in location. GAO reviewed VHA policies and files from the five selected VAMCs, and interviewed VHA, VISN, and VAMC officials. GAO also evaluated VHA’s practices using federal internal control standards.

What GAO Recommends

GAO is making four recommendations, including for VA to direct VHA to require VAMCs to document reviews of providers’ clinical care after concerns are raised, develop timeliness requirements for these reviews, and ensure proper VISN oversight of such reviews as well as timely VAMC reporting of providers to the NPDB and SLBs. VA concurred with GAO’s recommendations and described steps it will take to implement them.

Recommendations for Executive Action

Recommendation: The Under Secretary for Health should specify in VHA policy that reviews of providers’ clinical care after concerns have been raised should be documented, including retrospective and comprehensive reviews. (Recommendation 1)
Recommendation: The Under Secretary for Health should specify in VHA policy a timeliness requirement for initiating reviews of providers’ clinical care after a concern has been raised. (Recommendation 2)
Recommendation: The Under Secretary for Health should require VISN officials to oversee VAMC reviews of providers’ clinical care after concerns have been raised, including retrospective and comprehensive reviews, and ensure that VISN officials are conducting such oversight with the required standardized audit tool. This oversight should include reviewing documentation in order to ensure that these reviews are documented appropriately and conducted in a timely manner. (Recommendation 3)
Recommendation: The Under Secretary for Health should require VISN officials to establish a process for overseeing VAMCs to ensure that they are reporting providers to the NPDB and SLBs, and are reporting in a timely manner. (Recommendation 4)
As of this writing these were still open issues, click here to find the latest status.
The full report is available here.

New VA Hospital Rankings Show Nashville, Murfreesboro, and Memphis Still Suck.

New Ranking, same dismal report. In case you missed it, in Sept 2017 USA Today reported the following about the Memphis VA:

A veteran with diabetes and poor circulation checked into the Memphis VA Medical Center for a scan and possible repair of blood vessels in his right leg last year, but he ended up with a piece of plastic packaging that VA providers had mistakenly embedded in a critical artery.

and also this …

After her husband, Vietnam veteran Charles I. Davis, collapsed on the kitchen floor in their Atoka, Tenn., home in 2015, an MRI scan showed he had a tumor in his neck. She said when she asked doctors to check a scan taken at the Veterans Affairs the previous year, they found the tumor had been visible but VA clinicians had failed to diagnosis it. By the time they caught it, the tumor had damaged his spine and he is now paralyzed.

Some of the other stories you might remember:

  • Marion, where significant declines in patient safety culture and reported deaths prompted an investigation earlier this year.
  • Washington, D.C., where investigators found surgical shortfalls earlier this year that placed veterans in imminent danger.
  • Manchester, N.H., where The Boston Globe revealed dangerous conditions in July, including a fly-infested operating room and canceled surgeries.

Memphis woman back working at VA after being charged with aggravated assault

Veterans advocates ‘angered’ at story of failure at Manchester VA

Exclusive: Botched surgery, delayed diagnosis at a one-star ‘house of horrors’ VA hospital

OIG’s Top Physician Tells Senate Veterans’ Affairs Committee VHA Must Make Quality Health Care Its Most Important Mission

Remember how VA fixed the wait list scandal? Not so much at VA Nebraska-Western Iowa.

Here we go again, and if history teaches us anything it’s that this will not be an isolated incident. I remember back in 1991/1992 I was suicidal and spent some time at the VA hospital after getting out I had a referral to their program. So I waited for the call and waited and waited, I called and checked and waited and waited and then I became suicidal again so I called to ask them if it mattered to them. They got me into the program and I think the therapist who answered the phone saved my life that day.
So I am heartbroken when I hear the VA say, “Although no adverse patient outcomes occurred, some veterans waited longer for psychotherapy treatment,” the statement said. Delays have consequences and in order to know if they were adverse to the veteran we would need to know the VA definition of “adverse”. It may be very different than the what the veteran considers adverse.

Employees at the VA Nebraska-Western Iowa Health Care System kept an unauthorized, off-the-books waiting list for some Omaha mental health appointments, according to documents obtained by The World-Herald.

A four-star case of failure at Manchester VA – The Boston Globe

Dr. William “Ed” Kois outside his home in Newburyport, Mass. Kois believes many of his patients at the VA Hospital in Manchester, N.H., have received substandard care that has left many of them disabled.
Keith Bedford/Globe Staff

MANCHESTER, N.H. — This is what the US Department of Veterans Affairs says a four-star hospital looks like:One operating room has been abandoned since last October because exterminators couldn’t get rid of the flies. Doctors had to cancel surgeries in another OR last month after they discovered what appeared to be rust or blood on two sets of surgical instruments that were supposedly sterile.

Read the full article at:
“Late last year, in fact, the veterans affairs department raised Manchester’s quality rating from three stars to four, putting it in the top third of the entire VA system.” Seriously, it says it right there in black and white. I wish I was shocked and appalled but this is not new, over the decades of being in the system I’ve seen it before. From improper sterilization to mold in the air ducts, they always say they learned their lesson and they’ve implemented new procedures. Perhaps when they implement new procedures they should share with the rest of the hospitals so this can avoided because these are not new problems, they’ve happened elsewhere.Why does this continue to happen? Carelessness, complacency, incompetence? I don’t know but it’s happened repeatedly and if it repeats certainly patterns must be able to be identified and solutions implemented.

Previous Veterans Affairs Healthcare Inspections



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