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Author: WorkCompAcademy

Proposed Medicare Regs Crack Down on Over Prescribers

Medicare plans to arm itself with broad new powers to better control – and potentially ban – doctors engaged in fraudulent or harmful prescribing. The U.S. Centers for Medicare and Medicaid Services (CMS) described the effort late Monday in what’s known as a proposed rule, the standard process by which federal agencies make significant changes. Two of the changes mark a dramatic departure for the agency, which historically has given much higher priority to making medications easily accessible to seniors and the disabled than to weeding out dangerous providers.

For the first time, the agency would have the authority to kick out physicians and other providers who engage in abusive prescribing. It could also take such action if providers’ licenses have been suspended or revoked by state regulators or if they were restricted from prescribing painkillers and other controlled substances.   And the agency will tighten a loophole that has allowed doctors to prescribe to patients in the drug program, known as Part D, even when they were not officially enrolled with Medicare. Under the new rules, doctors and other providers must formally enroll if they want to write prescriptions to the 36 million people in Part D. This requires them to verify their credentials and disclose professional discipline and criminal history.

Currently, Medicare and the private insurers that run Part D know little about those writing the prescriptions – even those whose yearly tallies cost millions of dollars or who prescribe high volumes of inappropriate drugs.  ProPublica found that some of the doctors had been criminally charged or convicted, had lost medical licenses or had been terminated from state Medicaid programs serving the poor.

The changes would take effect Jan. 1, 2015. As part of the process, CMS will accept public comments until March 7 and could revise the proposals based on the feedback. Undoubtedly, the new rules would require some patients to change doctors – or force some doctors to apply to be part of Medicare. Among the changes Medicare proposes giving its outside fraud contractor the ability to more easily investigate suspicions of fraud. Currently, the contractor cannot directly access patient medical charts to assess whether the patient actually saw the doctor or had a condition that warranted the medication.  The contractor must go back to the insurers, which then request the records from doctors or pharmacies. Under the rule change, the contractor would be given the power to access the records directly. The inspector general of the U.S. Department of Health and Human Services has repeatedly pressed Medicare to make this change.

Medicare also proposes whittling down its list of “protected drug classes,” vital drugs for which insurers cannot impose restrictions on use. The agency wants to remove antidepressants and immunosuppressant drugs from this list, giving insurers more latitude to require patients receive prior approval before receiving certain brand-name medicines. The agency also said it may remove protection from antipsychotics, which can be inappropriate for seniors with dementia, after 2015.

Citation to Treatment Guideline Required to Award Home Health Care

The applicant, Elvin Salguero sustained an admitted injury consisting of partial amputation of his left fourth and fifth fingers and other body parts. After several hearings, the WCJ determined that the defendant had lost treatment control and that the claimant was entitled to treat with his free choice treater, Dr.Fred Hekmat. The case was resolved with a compromise and release to disputed body parts, and a stipulated award to 53% regarding the left 4th and 5th finger and psyche, with provision for future care for these admitted body parts.

With regard to the disputed claim for home care, the documentary record at the trial showed that the applicant was psychiatrically hospitalized at Brotman Medical Center after verbalizing intent to kill himself by jumping off a freeway overpass. More specifically, the report of his secondary psychiatric treater, Elena Konstat Ph.D., noted a significant suicide risk and significant depression in recommending a psychiatric hospitalization.

After his discharge, Konstat reported that Salguero “must remain in a safe and controlled environment closely monitored for his well-being. Therefore, 24/7 home cares [sic] assistance, and transportation to all medical appointments is recommended. Mr. Salguero is taking potent medication, and should not drive himself as he maybe [sic) a danger to himself, or others. In addition, his medications should be provided by preferably an LVN, or Psychiatric Technician.” After reviewing this report, the PTP stated that “”Based upon these further records from Dr. Konstat, I feel that certainly the patient requires the following: … [Par.] The patient requires 24/7 home care assistance by a psyche technician or LVN which is necessary to cure and relieve Mr. Salguero from the effects of his orthopaedic injury.” No UR report or other competent medical evidence was prepared in response to any of the reports discussed above, at least with regard to the home care request.

The case went to expedited trial on the limited issues of applicant’s request for authorization of a hand surgeon referral, stellate blocks and 24/7 home care. On cross-examination, he stated that he wanted to kill himself and had a specific plan to do this. Nonetheless, the WCJ found that good cause had not been shown to authorize his request for 24/7 home care. The applicant’s reconsideration petition as to the home care issue followed. The WCAB affirmed the denial in the panel decision of Elvin Salguero v Charles Gemeiner Cabinets and Insurance Company of the West.

The California Supreme Court has recently made clear that “[N]otwithstanding whatever an employer does (or does not do), an injured employee must still prove that the sought treatment is medically reasonable and necessary. That means demonstrating that the treatment request is consistent with the uniform guidelines (§ 4600, subd. (b)) or, alternatively, rebutting the application of the guidelines with a preponderance of scientific medical evidence. (§ 4604.5)” (Sandhagen v. WCAB, 73 CCC 981, 990.).

The Board has applied this principle to deny authorization for a given modality of care even where the defendant has neglected to carry out timely UR review. In Garcia v. Souplantation, 2011 Cal. Wrk. Comp.P .D. LEXIS 116, a request for authorization of epidural injections which was never rebutted via UR review was nevertheless held insufficient to support a need for such procedures where the ACOEM guidelines disfavored such a procedure and the treater requesting authorization never explained any basis for deviating from these guidelines. In Chairez v. Cherokee Bindery, 2012 Cal.Wrk.Comp.P.D. LEXIS 506, an award of 24/7 home care was reversed, mainly because of an unclear record. However, the board panel instructed the trial judge on remand that “In addressing the issue of home health care as medical treatment, the WCJ should consider that even if it is determined that a utilization review is untimely or otherwise invalid, the applicant still has a burden of proving that the requested treatment conforms with the requirements of Labor Code section 4604.5 by showing that it is in accord with the appropriate guidelines, or by rebutting the presumption of reasonableness of treatment in accord with those guidelines, or by showing that a variance from those guidelines is reasonably required to cure and relieve applicant from the effects of his industrial injury. [Sandhagen cited.] In short, an untimely or improper utilization review does not automatically require issuance of an award of the requested treatment. Instead, it must also be shown by applicant that the requested treatment is within the applicable guidelines or is otherwise reasonable medical treatment.”

There was no reference to any treatment guidelines or discussion of such guidelines in any of the reports submitted in this case. Dr. Konstat’s rather unusual request for 24/7 home care as a modality of care for severe depression. There is no mention of any such modality of care in Chapter 15 of the ACOEM guidelines regarding stress complaints.

Feds Launch Biggest Social Security Disability Fraud Busts in History

The Wall Street Journal reports that federal and local investigators plan to arrest 106 people today as part of one of the largest Social Security disability fraud busts in U.S. history. Several dozen arrests had been made early Tuesday. In addition to 102 Social Security disability beneficiaries, authorities are expected to arrest four people who helped them navigate the disability application process and coach them on how to get benefits, the person said. This includes one lawyer, one disability consultant, and two “recruiters,” the person said.

Federal and local prosecutors are expected to allege that scheme led to $24 million in fraudulent disability payments, the person said. A second person familiar with the arrests said the defendants claimed they were “unable to work at any job or leave their homes but had very active lives.”

The arrests come less than six months after federal and local authorities arrested more than 70 people in Puerto Rico on disability fraud charges. A former Social Security employee allegedly helped former employees at a pharmaceutical plant there obtain benefits.

The Social Security Administration is under pressure from Congress to explain what it is doing to tighten up the disability application process following a number of recent scandals. The Social Security Disability Insurance program has close to 11 million beneficiaries, and workers must prove they have physical or mental health problems that prevent them from working. The program has grown so quickly that it could have to begin cutting benefits for all recipients in 2016 unless Congress intervenes.

The New York Times now reports that eighty retired New York City police officers and firefighters are now charged. Scores of those charged in the case essentially stole in plain sight, according to a 205-count indictment and a bail letter, collecting between $30,000 and $50,000 a year based on fabricated claims that they were completely incapacitated by serious psychiatric disorders. Many said that their actions in response to the Sept. 11, 2001, terrorist attacks were responsible for their psychiatric conditions, such as post-traumatic stress disorder, anxiety or depression.

But their Facebook pages and other websites, according to the court papers, tell a starkly different story. Photographs culled from the Internet that show one riding a jet ski and others working at jobs ranging from helicopter pilot to martial arts instructor. One is shown fishing off the coast of Costa Rica and another sitting astride a motorcycle, while another appeared in a television news story selling cannoli at the Feast of San Gennaro on Mulberry Street in Manhattan. Prosecutors charge that they were coached by the scheme’s organizers to appear disheveled and disoriented during interviews, in which doctors initially evaluated their disability applications before finding them to be mentally disabled and incapable of any work whatsoever.

WCAB Limits Discovery of Psychiatric Records

Kelly Snow filed an Application for Adjudication of Claim against her employer, Health Net, alleging that she sustained an industrial injury to her upper extremities, wrist, shoulders and back. She later filed an amended Application, alleging additional injury to her psyche. She apparently disclosed in her deposition that she had been treated by Ms. Bradley, a Licensed Clinical Social Worker in the past.

Defendant attempted to obtain the records of Ms.Bradley and to depose her, contending that these records are relevant to causation of the alleged psychiatric injury and apportionment of permanent disability caused by that injury. The workers’ compensation administrative law judge (WCJ) denied applicant’s Petition to Quash Subpoena Duces Tecum, denied applicant’s Petition to Quash the Deposition of J. Bradley, LCSW; and ordered applicant to sign a release for the records of J. Bradley, LCSW and ordered the deposition to go forward. Applicant filed a timely, verified Petition for Removal, requesting that the Appeals Board rescind the Orders. Removal was granted in the panel decision of Kelly Snow v Health Net.

Applicant contends in her Petition that both she and Ms. Bradley may assert and have asserted the psychotherapist-patient privilege and refused to disclose confidential communications between them; and that because Ms. Bradley is neither a physician nor a psychologist, pursuant to Labor Code section 3209.3(a) and (b), her records cannot be reviewed by an evaluating qualified medical evaluator (QME), pursuant to Administrative Director Rule 35(a)(l) and (2) (Cal. Code Regs., tit. 8, § 35(a)(l) and (2)) and therefore are not discoverable.

The WCAB concluded that as to whether the records of Ms. Bradley can be provided to the QME for review, Rule 35(a)(5) provides that “[n]on-medical records … which are relevant to determination of medical issue(s) in dispute” may be provided to a QME. Even though Ms. Bradley is not a physician pursuant to section 3209.3( a) and (b ), her records and her testimony are “non-medical records” and may be sent to the QME.

As to the psychotherapist-patient privilege, as a licensed clinical social worker, Ms. Bradley is a “psychotherapist” pursuant to Evidence Code section 1010(c). Applicant is the “holder of the privilege” pursuant to Evidence Code section 1013(a). Both she and Ms. Bradley may claim the privilege to refuse to disclose confidential communications between them, pursuant to Evidence Code section 1014(a) and (c). However, Evidence Code section 1016 provides: “There is no privilege under this article as to a communication relevant to an issue concerning the mental or emotional condition of the patient if such issue has been tendered by: (a) The patient.”

However, the waiver contemplated by Evidence Code section 1016 may not be a complete waiver of the privilege but only a limited waiver concomitant with the purposes of the section. As the Supreme Court stated In re Lifschutz (1970) 2 Ca1.3d 415 that the patient is not obligated to sacrifice all privacy to seek redress for a specific mental or emotional injury; the scope of the inquiry permitted depends upon the nature of the injuries which the patient-litigant himself has brought before the court.

The WCAB noted that in this case, Ms. Bradley wrote a letter to the process server of the SOT for her records, stating: “The records that I have regarding the above named precede the accident of March 14, 2011 by a number of years. As these records do not relate to this event or injuries, I do not feel comfortable in releasing her private information.” Therefore, there is an issue as to whether the records of Ms. Bradley relate to the mental conditions that applicant has disclosed in this case or whether they relate to “other aspects of [her] personality,” in which case disclosure may not be compellable. For this reason, the WCJ in his Report and Recommendation recommended that the WCAB grant applicant’s petition so that there can be further consideration of whether some or all of Ms. Bradley’s records may still be privileged, despite applicant’s allegation of injury to psyche in her injury of March 11, 2011.

Thus the WCAB agreed with the Recommendation of the WCJ and granted removal, rescinded the Orders dated June 19, 2013, and returned the matter to the trial level for further proceedings.

WCIRB Report Analyzes Increase in Claim Frequency

The WCIRB has released a report analyzing the elevated level of indemnity claim frequency that has persisted in California since 2010 and run counter to indemnity claim trends in other states. The Analysis of Changes in Indemnity Claim Frequency – 2013 Report, which is available on the WCIRB website (, identifies possible factors influencing the 2012 indemnity claim frequency increase and compares them to those factors impacting the 2010 increase.

Among the findings of the report are:

  • While the 2010 indemnity claim frequency increase was experienced in many states, the 2012 frequency increase appears to be unique to California.
  • Both the 2010 and 2012 frequency increases appear to be influenced by an increase in the number of late-reported indemnity claims and cumulative injury claims.
  • The 2012 increase in cumulative injury claims was focused primarily on permanent disability claims and claims involving injuries to multiple body parts. In contrast, the 2010 increase was spread across many types of injuries.
  • The 2010 indemnity claim frequency increase was significantly dampened by the impact of shifts in industrial mix towards less hazardous employments. In 2012, as the economy recovered in more hazardous industries such as construction and manufacturing, shifting industrial mix tended to slightly increase claim frequency.
  • While the 2010 indemnity claim frequency increase was generally experienced across all California regions, the 2012 increase was experienced primarily in the counties in and around the Los Angeles basin.
  • The economic recovery that continued through 2012 resulted in a higher number of newer workers in the labor force, and newer workers are often more likely to suffer a workplace injury.
  • A significant portion of the 2010 indemnity claim frequency increase was experienced in smaller indemnity claims that may have been medical-only in the past. Preliminary information suggests that the 2012 increase was more heavily concentrated in larger claim sizes.

The full report is available in the Research and Analysis section of the WCIRB website.

Fullerton Business Owner Gets Five Year Sentence in Fraud Case

The Orange County Register reports that a Fullerton tree-trimming business owner who filed workers’ compensation insurance claims for one worker killed in a wood chipper and a second seriously injured in an on-the-job vehicle accident–despite never having paid premiums for the employees–was sent to prison for five years.

Jose Luis Guerrero, the 45-year-old owner of Jose Martinez Tree Service Inc., had pleaded guilty to under-reporting more than $2 million in payroll to the State Compensation Insurance Fund between March 2005 and March 2009.

It was a review of the Nov. 7, 2007, wood-chipper death of Gabriel Gonzalez by State Compensation Insurance Fund officials that uncovered the widespread fraud, according to Deputy District Attorney Debbie Jackson. For four years beginning in March 2005, Guerrero under-reported his payroll to the state insurance fund by more than $2 million so he would have to pay less in workers’ compensation insurance premiums, according to the Orange County District Attorney’s office, which also accused him of illegally paying some of his employees in cash.

Guerrero pleaded guilty Dec. 20 to 20 counts of intent to evade taxes, four counts of false or fraudulent statements to reduce premiums, and two counts of making fraudulent statements to obtain or deny compensation, all felonies.

He also admitted to sentencing-enhancement allegations for aggravated white collar crime between $100,000 to $500,000 and theft exceeding $150,000, and also pleaded guilty to misdemeanor possession of an assault weapon.

DWC Post s RBRVS Fee Schedule Updates Effective January 1, 2014

Pursuant to Labor Code section 5307.1(g)(2), the Division of Workers’ Compensation (DWC) has issued an Administrative Director Order posting adjustments to the Resource Based Relative Value Scale (RBRVS)-based physician services and non-physician practitioner services section of the official medical fee schedule (OMFS) to conform to changes in the 2014 Medicare payment system as required by Labor Code section 5307.1. The update order includes adoption of the 2014 relative value units, the 2014 CPT codes, and updated conversion factors (including the Medicare Economic Index and relative value scale adjustments). The changes take effect January 1, 2014.

In accordance with SB 863, the Acting Administrative Director conducted a rulemaking action and adopted the new physician fee schedule based upon the RBRVS. The regulations were filed with the Secretary of State for publication in the California Code of Regulations on September 24, 2013. Thereafter, amendments to the regulations were adopted to amend the RBRVS-based fee schedule to eliminate use of the federal Office of Workers’ Compensation Program (OWCP) relative value units because the structure of the OWCP data file would result in erroneous fee calculations for 21 procedures. (A total of 81 procedures that would have been priced using OWCP values will instead be paid By Report.) The amended regulations were adopted on December 13, 2013 and submitted to the Office of Administrative Law to be effective January 1, 2014.

The RBRVS-based fee schedule for physician and non-physician practitioner services (based on the regulations and the update order) is posted on the DWC official medical fee schedule webpage. The regulations and update order are effective for services rendered on or after January 1, 2014.

More information and the adjustments to the physician services and non-physician practitioner services section of the OMFS can be found on the DWC OMFS page.

Court of Appeal Says Rating Need Not Be “Complex and Extraordinary” to Use Almaraz/Guzman Analogy

Arthur Cannon injured his left foot and heel while working as a police officer for the City of Sacramento. He was diagnosed with plantar fasciitis and provided with physical therapy, cortisone injections , and an orthotic device. His primary treating physician found him permanent and stationary in January 2010, with no impairme nt of his activities of daily living and capable of performing his usual occupation.

An agreed medical examiner, Dr. William Ramsey, agreed Cannon was permanent and stationary and that there was no impairment but recommended that he be precluded from such things as prolonged running. Dr. Ramsey explained in a supplemental report that at the time of his original report, he was “unable to offer any impairment from a strict interpretation of the AMA Guides, 5th Edition” because “other than some tenderness, no objective abnormalities were identifiable.” Now, however, Dr. Ramsey determined that it was acceptable to characterize Cannon’s residual condition “using a gait derangement abnormality” “by analogy, using Almaraz/Guzman-II as a basis.” Noting that Cannon’s problem was “relatively mild,” with “the left heel causing weightbearing problems” and the likelihood that the condition “would . . . be aggravated appreciably by running activity on other than a short-term basis,” Dr. Ramsey recommended characterizing Cannon by reference to “Table 17-5, page 529,” as having “a limp, despite the absence of any arthritic changes about adjacent joints, equivalent to 7% whole person impairment.”

Ramsey continued to explain in yet another subsequent report that because Cannon’s heel pain “interferes with weightbearing activities, particularly running,” he “thought that by analogy, it would be similar to an individual with a limp and arthritis, resulting in the 7% impairment recommended.” He conceded however that that “heel pain, or for that matter, other aspects of pain that do not have any accompanying objective measurement abnormalities, do not rate anything in the AMA Guides, whether or not these problems interfere with one’s activities.”

In a trial brief, the city argued that a rating by analogy under Almaraz/Guzman would be proper only if the case could be characterized as “complex or extraordinary,” which Cannon’s injury could not be. The workers’ compensation judge (judge) agreed, finding that Cannon had no permanent disability because his medical condition was not complex or extraordinary and therefore did not warrant departure from a strict application of the AMA Guides.

Cannon petitioned for reconsideration, arguing that a case does not have to be complex or extraordinary to be rated by analogy under Almaraz/Guzman. The board granted reconsideration and, agreeing with Cannon in a split panel decision, rescinded the judge’s findings and award and returned the matter to him for a new permanent disability rating based on Dr. Ramsey’s findings.

The Court of Appeal affirmed the award in the unpublished case of City of Sacramento v WCAB (Cannon).

The city argued that a rating by analogy under Almaraz/Guzman is permissible only in complex or extraordinary cases. The Court of Appeal disagreed. It concluded that “this is an unwarranted interpretation of the Sixth District’s decision in Milpitas Unified. What the Sixth District said was this: ‘The Guides . . . cannot rate syndromes that are ‘poorly understood and are manifested only by subjective symptoms.’ [Citation.] [¶] To accommodate those complex or extraordinary cases, the Guides calls for the physician’s exercise of clinical judgment to assess the impairment most accurately.’ (Milpitas Unified, supra, 187 Cal.App.4th at p. 823, italics added.) Thus, the Sixth District was using the term ‘complex or extraordinary cases’ to describe ‘syndromes that are ‘poorly understood and are manifested only by subjective symptoms,’ which the AMA Guides do not, and cannot, rate.”

“It is undisputed that Cannon’s condition — plantar fasciitis — is manifested only by his subjective experience of pain. Thus, his condition appears to fall right into the category of cases the Sixth District was describing in Milpitas Unified, where the AMA Guides ‘calls for the physician’s exercise of clinical judgment to assess the impairment most accurately.’ (Milpitas Unified, supra, 187 Cal.App.4th at p. 823.) Dr. Ramsey performed that assessment here and determined that Cannon’s plantar fasciitis resulted in a 7 percent whole person impairment equivalent to a limp with arthritis. The city has shown no error in that assessment and no error in the board’s decision based on that assessment.”

CMS Publishes Notice of Proposed Rule Making Regarding Appeal Process

On December 27, 2013, CMS issued a Notice of Proposed Rule Making relating to circumstances where “applicable plans” (liability insurance, no-fault insurance, and workers’ compensation law or plans) can appeal recoveries which are sought by Medicare under the MSP directly against applicable plans. Organizations or individuals seeking to have commentary considered should provide their recommendations via one of the approved delivery methods as specified in the NPRM no later than 5 pm on February 25, 2014.

The appeals process proposed within this NPRM will strictly be for “applicable plans” as Medicare beneficiaries currently have existing appeal rights where the beneficiary is listed as the debtor. Because there is currently no appeals process for applicable plans in a similar situation, and the SMART Act called upon CMS to create an appeals process for applicable plans, this NPRM has been issued in the efforts to give applicable plans the same rights to appeal as a beneficiary currently has available.

As it relates to the SMART Act, Section 201 specifically requires Medicare to promulgate regulations establishing a right of appeal and appeals process under which the applicable plan involved, or an attorney, agent, or third party administrator on behalf of such plan, may appeal a statement of reimbursement amount. Therefore, this NPRM has been issued to comply with the aforementioned requirement of the SMART Act.

While CMS has noted that the industry has expressed interest in an appeal process for determinations regarding Workers’ Compensation Medicare Set Asides (WCMSAs), this NPRM does not address this issue (CMS noted that it will be addressed separately).

Floyd, Skeren and Kelly LLP Announce Disabled Veterans Litigation Unit

Floyd, Skeren and Kelly LLP is pleased to announce the formation of its disabled veterans litigation unit. The attorneys in this group represent veterans who have claims for benefits pending before the Veteran’s Administration.

Veterans qualify for disability benefits if they suffer from a current diagnosis that has a “nexus” with military service. The scheme of benefits is very similar to workers’ compensation for civilian workers. The veteran need only show active military service, a discharge at greater than dishonorable service and a “nexus” between the current disability and military service to receive benefits. The nexus can be established by direct injury, an aggravation of a disease by military service, or by a presumption of causation imposed by federal law or in other ways. A nexus issue in veteran cases has the same implication as an AOE-COE issue in workers’ compensation claims.

Vietnam veterans, for example, who have had “boots on the ground” in Vietnam, even for one day, qualify for the Agent Orange presumption. Agent Orange is one of the herbicides and defoliants used by the military as part of its herbicidal warfare program. Between 1962 and 1971, the military sprayed nearly 20 million gallons of Agent Orange over Vietnam. The product contained an extremely toxic dioxin compound. Dioxins and furans are some of the most toxic chemicals known to science. Vietnam veterans who develop a number of diseases years after service such as ischemic heart disease, diabetes mellitus type II, a number of cancers including prostate cancer (and other listed diseases) are presumed to have a nexus between military service and those medical conditions;

Once a nexus has been established, a veteran may obtain medical care in any VA facility nationwide. This may include free care for health problems in addition to those that are service connected. The veteran may also receive a monthly tax free disability payment. The disability is rated using a rating schedule similar to the workers’ compensation scheme. The rating can increase over time if the condition worsens. There is no time limit to request an increase of a disability award. The system provides death and survivor benefits, payment for at home attendant care, educational and rehabilitation benefits and more.

Another veteran program provides a pension to war era veterans who are totally disabled for any reason even if there is no service connection. This program is “means tested” meaning that current income is measured and used to offset this benefit. If a war era veteran is 65 years of age or older, they are presumed to be totally disabled and entitled to this pension. The means testing allows the veteran to reduce any income by current medical expenses. Thus, even veterans who have a source of income may qualify for a pension if their income is currently used for medical care.

If a veteran’s claim for disability compensation or pension is turned down by the VA Regional Office (RO), they may seek the services of an “accredited” advocate to appeal an unfavorable decision. Lay and attorney advocates must be accredited by the Office of the General Council of the Veterans Administration to assure a minimal level of competency before they can serve a veteran. The appeal begins at the Regional Office where the claim was filed. The Veteran can ask for a de-novo review of the file by a Decision Review Officer (DRO). If unsuccessful, the claim can then be appealed to the Board of Veteran’s Appeals (BVA). The BVA decision can be appealed to the Court of Appeals of Veteran Claims (CAVC) and ultimately to the U.S. Supreme Court.  These cases are quite similar to workers’ compensation litigation in that they heavily involve forensic medical issues.  Practitioners need considerable experience with medical terminology and medicine in general.  Generally advocates can be paid a contingent fee of 20% of accrued and unpaid benefits as of the time of the successful appeal.  Thereafter the veteran retains 100% of the balance of the award.

Three of our attorneys, Rene Thomas Folse, Chris Lear and Tim Morgan have been accredited by the VA Office of General Council to represent veterans.  Rene is a Vietnam veteran, and Chris is also a veteran who has had several deployments in the Persian Gulf. Both served in the U.S. Army. Tim has a background in the civil litigation of medical malpractice claims and will assist with the complex forensic medical issues.

Any veteran who would like a no-cost consultation about his or her right to benefits may call Rene, 818 651-7028.  He is the litigation group lead counsel, and does initial client contact and intake. Since this is a federal program, we can represent veterans nationwide.  In those cases we will conduct our interviews by teleconference.