Introduction of Special Guest Speaker

We have a special guest speaker today, Dr. Craig Bash, and his sidekick, Bill Creager. Bill has been a veterans’ advocate for a long time. Let’s get the show started. How are you doing today, Dr. Bash?

Dr. Bash: I’m good, I’m good. Do you guys have any topics you want to talk about? We can stick to the basics, or we can venture off and get some good advice on how to effectively file your claim so that the personnel who work at the VA can make it easier to adjudicate. Is that a good possibility?

Host: Yeah, I think we can do that. Bill Creager is here. Bill, do you want to tell us a little about your background?

Bill Creager: Sure, I was a Marine for a few years, to say the least, and then I began helping vets with their claims as a certified service officer for the Marine Corps League. From there, I went with the State of Maryland and Paralyzed Veterans of America, representing claims, monitoring healthcare in hospitals, and representing appeals at the Board of Veterans Appeals. I was admitted to practice in the Veterans Court and then took an opportunity with the VA itself as a decision review officer at the Case Resource Center in Washington, D.C. I retired just a few months ago. I’ve known Dr. Bash for a long time; we’ve worked well together in the past, and I’m looking forward to helping him with some of the cases that come to his attention.

Making the Case Easy for the Rater

Dr. Bash: One of the things you taught me a long time ago was to always try and make the case easy for the rater. Do you want to talk about that a little bit?

Bill Creager: Sure. If we think about what VA requires of those raters, we can understand how to get our case favorably resolved in the easiest way possible. One of the most important things is the evidence. I’ve found over the years that many veterans think they have a pretty good claim but don’t fully understand that you need some sort of medical evidence to back up what you’re saying. Presenting that evidence, and with VA rules allowing private physicians to fill out forms and express their opinions, we can frontload a claim with all the necessary evidence and arguments. VA has initiated projects to accelerate those claims, and it’s in everyone’s interest to get the proper advice, gather the necessary evidence, and submit it all at the beginning so you don’t find yourself in that appeal process, which takes so very long.

Host: Would that be the fully developed claim?

Bill Creager: Yes, that’s exactly what I had in mind. And I can say that it works because it happened to me. They granted my claim for an increase and started paying me within one month from when I filed the claim. I was surprised, but it works.

Dr. Bash: Bill, you’ve only been doing this for 40 years, so you got it right in one month?

Bill Creager: Yes, but veterans can do that if they get help from an accredited representative, submit it through that representative, and have all the necessary evidence for VA to decide the claim. When I was presenting claims to VA, I always knew what the rater needed to grant the claim and gave it to them right up front.

Host: Unfortunately, not enough veterans get started off on the right foot. They don’t have the knowledge or are misinformed, which is where they get in trouble, and claims drag on for years. Once they start getting denied, it puts a stigma on the claim, and it seems like VA wants more additional evidence than what you have in your possession.

Dr. Bash: Hey Bill, how does it work if a claim gets denied and then gets granted later? Does that show up as an error on the rater? Is that part of why they don’t want to change it, or how does that work?

Bill Creager: A different opinion in the future does not. In fact, raters rarely ever know the outcome of an appeal. If an appeal goes to Washington, the majority are remanded by the Board of Veterans Appeals for further development of the evidence and readjudication. It would not go back to that original office in most cases; it would go to the Appeals Resource Center, where it would be revisited. So the original decision maker would not be involved and would likely not know the subsequent outcome.

Dr. Bash: What if it’s a CUE, like a clear and unmistakable error? Does that go back to the rater?

Bill Creager: No, a claim for clear and unmistakable error is a new claim. Upon receipt, it’s adjudicated by someone who was not previously involved.

Dr. Bash: That makes sense, though, to do it that way.

Host: Well, it does make sense, and that’s why you keep running into the same problems. I’ve had a judge for 15 years who keeps remanding the claim back for further development, but nothing ever gets done to it. They wait two or three years and then send it back up to the judge. That’s been going on for years. It would work wonderfully if they would change judges out, you know, get a judge who could read and maybe understand.

Bill Creager: I understand what you’re saying. We’re speaking of the regional office level, not the Board of Veterans Appeals judges. The original raters who decide the claim would not then be involved with the appeal. It would be done by a decision review officer in some cases when you ask for a hearing. The Board of Veterans Appeals was not affected by that particular case.

Dr. Bash: What is the authoritative level of a DRO? Do they have the capacity to make a complete new decision with no backlash, or how does that work?

Bill Creager: Yes, the decision review officer reviews and makes a new decision upon receiving an appeal. They have the authority to grant the appeal, order additional development if it was deficient, or find that a prior decision was clear and unmistakable error. They have a broad general authority.

Dr. Bash: A lot of cases I see where the veteran has a claim for some disability, but their symptoms match up with a different disability. The DRO can’t really change the diagnosis in that case; they need to get a new medical opinion to clarify the diagnosis.

Bill Creager: That’s correct. A decision review officer, like raters and Board of Veterans Appeals judges, may not use their own opinions to resolve medical questions. They must point to independent medical evidence in the file to support their conclusions.

Dr. Bash: The case where the diagnosis is incorrect is a big problem. I think that’s where veterans go off on the wrong foot a lot because they don’t know medicine well enough to match up their symptoms with the right diagnosis.

Bill Creager: True. For example, some veterans might feel like they’ve suffered emotional trauma in service and now have post-traumatic stress disorder. However, they may not have the requisite training and knowledge to diagnose themselves. The adjudicator must point to what the medical experts provide in the way of a diagnosis. If a veteran disagrees with the diagnosis, they need a competent medical source to provide an alternative diagnosis and explain why the prior diagnosis was incorrect.

Host: So, in other words, they need to see perhaps an outside psychiatrist?

Bill Creager: Not necessarily. It doesn’t have to be outside. I’ve adjudicated cases where I resolved a difference of opinion between two VA physicians. As the decision review officer, I was required to choose which one I sided with.

Dr. Bash: How do you resolve the issue of two opinions, like one from a nurse practitioner or a PA and one from a physician? What’s your philosophy on that?

Bill Creager: VA has guidance on how to weigh the value of the evidence. The criteria include the credentials and degree of expertise of the opining expert. The reasoning offered is also crucial. For example, if one doctor says something is related to service and gives no explanation, while another says it’s not related to service and provides a persuasive narrative, one would naturally tend to go with the latter.

Host: But they wouldn’t have to, would they? If the veteran had other evidence that supported their favorable doctor, couldn’t that help?

Bill Creager: Yes, you’re right. It’s an exercise of judgment. You’re not compelled to favor one over the other, and you’re not compelled to agree with a medical opinion because it’s from a VA source over a private source.

Host: A few years ago, the VA came out with a rule about PTSD, stating that the veteran could not get a medical opinion from an outside source unless that source was a treating physician. Is that still part of the game, or has it changed?

Bill Creager: That rule was specifically under the revised criteria regarding the stressor. When VA changed the rule to allow a grant of service connection without proof of a stressor event, it limited the grant to only VA examiners. If your stressor event is substantiated by evidence, VA can accept a medical opinion linking your diagnosis to that event from any competent medical source.

Host: That makes sense. It might be confusing to some people because some of the early training didn’t make that differentiation clear.

Bill Creager: Yes, that might be the case. It’s important to note that a veteran’s claim is only as strong as their representation. They need strong representation to get their claim through the VA. Unfortunately, many claims are done improperly, and by the time you get done, you’re claiming for PTSD when you should be claiming for a broken foot.

Dr. Bash: What would you do if a claim had 20 issues? How do you handle that?

Bill Creager: Most people would take a nibble at it each day while working on simpler cases to meet their production requirements. If you sit on a 25-issue case, it might take days, so you have to work efficiently.

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