Dr. Bash: Hey Bill, does a claim with four issues count as one patient, or is there some kind of ratio?

Bill: Well, there are two methods of accounting, you might say, for the VA’s inventory or the VA’s workload, where all these cases are. VA does, from time to time, measure the number of veterans served or the number of issues served. Depending on the report you’re reading, it may report the number of veterans served or the number of issues served, and that varies from time to time and place to place, depending on the need for the report.

For example, the Board of Veterans Appeals puts out an annual report. You can read that annual report online by Googling it. It explains how the board differentiates and counts results. It’s probably worthwhile if someone is interested to actually read the report done by the Chairman of the Board of Appeals each year to see what the board does with their cases.

Dr. Bash: So as far as the rater’s work product, does it have to do with four patients a day or four cases? Is there some variability?

Bill: That was recently revised for most raters. Depending on an individual’s level and experience, they may initially be assigned and required to complete cases that result in two points of credit per day. A qualified rater would be required to do four and one-quarter points of credit per day. They may achieve that by perhaps doing one 20-issue case or five one-point cases, according to the formula. That was recently revised for raters but not for decision review officers. Decision review officers were still under the older system at the time of my retirement a couple of months ago. They were required to do 4.25 points per day.

Dr. Bash: So, as a doctor, I find a primary issue and then all these secondary issues that most people don’t talk about. If a rater gets a case and has all those secondary issues, does he get credit for adding those into the rating? How do they deal with that?

Bill: Yes, it’s a proportional system. If an individual filed a claim for, let’s say, three issues, and after it was adjudicated it turned out to be three issues, the rater would then have 1.5 points or credits towards their work for those three issues. If it grew to five issues, they would get two points. If that’s clear, I hope.

Dr. Bash: Funny ratios. So, if they find a bunch of secondary issues, that helps them with their points, making it more efficient. That makes sense.

Bill: Sure, sure. By the way, we were speaking before of the regulations governing PTSD indications. You’ll find that at 38 CFR 3.304(f), which describes how VA is required to adjudicate PTSD claims for service connection. Only in part (f)(3) does it state that the opinion must come from a VA practitioner or contractor.

Dr. Bash: Let’s go back to those secondary conditions again for a second. So, the rater goes along and sees these secondary conditions. But if he doesn’t have a medical opinion linking them, he has to either overlook them or get a medical opinion on point, right, Bill?

Bill: Generally speaking, it would be an error to overlook them. If an issue is raised by the evidence or expressly claimed by the veteran, depending on the nature of the issue, it may be incumbent upon the rater to take jurisdiction on that issue and either invite the claim, suggest to the veteran, or ask the veteran if they want to claim that specific disability. In other cases, such as complications of diabetes, it would be incumbent upon the rater to address all complications of diabetes shown in the record based on the medical evidence. It would not be necessary for the veteran to expressly claim those complications.

Dr. Bash: So sometimes that depends on who the medical examiner is. For example, you have a nurse practitioner or PA who does an abbreviated exam and doesn’t really talk about the peripheral neuropathy, retinopathy, or nephropathy versus a doctor who might go through a detailed examination and talk about those issues. That gives the rater a lot more information to help with their rating, right?

Bill: True. There is, however, some guidance that would prompt that exploration. If VA were to receive a claim for service connection for diabetes, typically an initial evaluation would be performed, and the DBQ (Disability Benefits Questionnaire) for diabetes would prompt the examiner to identify complications that the patient suffers from. If needed, those complications would then be referred to a specialist to address and quantify in order to derive the correct rating for diabetes and all its complications.

Dr. Bash: So the rater would send it out to the specialist from the DBQ?

Bill: Yes, the DBQ is specifically designed to solicit a statement from the examiner on the presence of any complications.

Host: Now, on the DBQs, they’re not the same if you get a C&P (Compensation & Pension) examination and they use a DBQ. It’s different from the form you pull off the internet to give your doctor to fill out, right? They have two sets of DBQs.

Bill: There are many more than two. The DBQ is part of an evolution. The original intent was to create a standardized examination report to solicit specific findings necessary to compare with the schedule for rating disabilities, providing consistency in the information given by the examiners. This improves the ability of the rater to use that report because it is designed to solicit those specific findings found in the rating schedule. This process has been expanding and modifying over many years.

Dr. Bash: Like Gerald was saying, I’ve seen internal DBQs that say “for internal use only.” These DBQs have prompts for rationale and a lot of details they want the doctor to explain, more than the DBQs available on the VA’s website. Have you seen that or noticed that? How does that work?

Bill: Yes, I’ve seen different variations on the forms over time. My understanding is that those modifications were initiated to ensure the accuracy of the report and to solicit the best information possible to decide the claim. However, recognize that trying to mold the world of medicine to fit the world of adjudication is not always comfortable.

Dr. Bash: For example, the rating schedule for mental health evaluations in the 1990s chose examples of symptoms as justifications for higher or lower ratings, but that list was never intended to be all-inclusive. A veteran may suffer a symptom not on that list. One unique to PTSD is the flashback or intrusive recollections. While sleep impairment and mood issues are present on the list, flashbacks and intrusive recollections are not, which is problematic for accurate evaluations.

Host: The veteran should be afforded the same DBQ that a C&P examiner uses. It’s problematic to have internal use only DBQs.

Bill: Yes, it should be consistent. There’s a good example. Last year, I had an issue with my heart disease and filed for an increase. I did it online, filed under the fully developed claim, and attached information from my outside doctor. I got a note back from the VA to fill out a DBQ for hypertension, which wasn’t what I needed. So I printed off the heart DBQ, took it to my doctor, had it filled out, and submitted it. It knocked me out of the fully developed claim process, but I got a decision in six months.

Host: Things like that happen. We spoke about the fully developed claim, but the decision-ready claim compels VA to make the award within one month following receipt of the claim. The fully developed claim does not.

Dr. Bash: What’s the difference between decision-ready and fully developed claims?

Bill: The decision-ready claim compels VA to make the award within one month following receipt of the claim. The fully developed claim does not. It’s a reward for using a service organization and completing the development for VA upfront. When you team with a knowledgeable person and give VA a complete package, it speeds up their ability to make a decision.

Host: What if I didn’t have the right to appeal?

Bill: Of course, you still have the right to appeal. It would not impact your right to appeal in any way.

Dr. Bash: Thanks for sharing your insights, Bill. Thank you all for listening. That ends this show. Now I’m going to zoom off.