VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[Sanman]

I hadn't seen/heard any updates related to that here, but we tend to run a bit behind what's going on nationally. Should be...interesting. I've heard it's possible to do them competently and still make a decent financial return, but not sure (and I wonder if it varies by region).

I have never had to do them since becoming licensed and have no interest in starting now. That said, it really will depend on how they hire contractors. They used to hire a person who then went and subcontracted this to the clinicians on hired them as 1099s. Hence the poor pay. If you contract clinicians directly, some will have the option being paid decently for the work. They still won't have access to DOD records though.

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[WisNeuro]

I have never had to do them since becoming licensed and have no interest in starting now. That said, it really will depend on how they hire contractors. They used to hire a person who then went and subcontracted this to the clinicians on hired them as 1099s. Hence the poor pay. If you contract clinicians directly, some will have the option being paid decently for the work. They still won't have access to DOD records though.

On the neuro side, I doubt they'll pay even half of what we charge for IME work, which this is. So, no-go for me. I saw the rates for the subcontracted out evals a few years back. It was laughable, unless you could do a full eval, with documentation, in about 30-45 mins a pop.

 

[Fan_of_Meehl]

Y

Unfortunately, I've been at some facilities where the in-house C&P standards left a lot to be desired IMO so

I've also never had to do them so I won't complain about keeping that streak alive.

Yeah, there are some good/decent C&P examiners in the VA system but we definitely have our share of 'rubber stampers' who will just sling a PCL-5 and call it a day

 

[Sanman]

Y
Yeah, there are some good/decent C&P examiners in the VA system but we definitely have our share of 'rubber stampers' who will just sling a PCL-5 and call it a day

I do wonder how this was being counted at the VA. Neuropsych aside, doing this a 90791 is laughable generally.

 

[erg923]

They still won't have access to DOD records though.

Whats this about?

Restrict potential supporting/corroborating evidence, treatment history/assessments, and collateral info about the veteran from the eval? Why? Is this noted as a limitation of the evaluation by the contracted C&P evaluators? It is suppose to be an IME, right? Could one even do a legitimate IME if the employer declined to release relevant medical records?

 

[WisNeuro]

Whats this about?

Restrict potential supporting/corroborating evidence, treatment history/assessments, and collateral info about the veteran from the eval? Why? Is this noted as a limitation of the evaluation by the contracted C&P evaluators? It is suppose to be an IME, right? Could one even do a legitimate IME if the employer declined to release relevant medical records?

Ethically, one would not agree to an IME if relevant medical records were withheld. Most of my boarded colleagues explicitly state that they will cancel the evaluation if they do not have records prior to it taking place.

 

[cara susanna]

I do wonder how this was being counted at the VA. Neuropsych aside, doing this a 90791 is laughable generally.

I don't think we billed for C&P using clinical codes. I never coded encounters for C&Ps, anyway.

We were told that they were generally 90 min to 1 hr but we had 4 hrs total for them. In addition to the clinical interview and chart/records review, we would usually give some objective testing like the PAI or MMPI-2.

 

[WisNeuro]

I don't think we billed for C&P using clinical codes. I never coded encounters for C&Ps, anyway.

We were told that they were generally 90 min to 1 hr but we had 4 hrs total for them. In addition to the clinical interview and chart/records review, we would usually give some objective testing like the PAI or MMPI-2.

We were consulted in neuro occasionally as part of the exams. But, it was always in the larger context and came with a clinical question, so it was more of a general clinical eval, so we still used codes. Though, in the non-VA world, these would likely not be billable by insurance.

 

[AbnormalPsych]

Saw a few news stories about VA contracting out 100% of C&P exams. I know it's been in the works for sometime, but looks like it's gonna happen. Are all you VA people ready for all of the C&P exams to be done by diploma mill grads who can't find better work and are willing to either work for the low pay to do an adequate eval, or do the eval so quickly as to throw out any shred of competency and integrity they had left to pump out as many as they can to make a decent wage?

You get PTSD! and You get PTSD!

 

[WisNeuro]

You get PTSD! and You get PTSD!

Don't forget "Organic brain syndrome" or whatever they're calling it on SC these days.

 

[AbnormalPsych]

Wut

 

[WisNeuro]

Wut

Back in my VA days, some of the OEF/OIF.OND vets were being connected with organic brain syndrome/disease as a compensable condition.

 

[summerbabe]

Random question - why do I seem to see 30% and 70% SC for PTSD so often (instead of 40% or 80%)? Is this related to how 30% and 70% bumps you up from a lower SC range? How C&P evaluates impairment due to PTSD? Me seeing patterns that aren't really there?

 

[thebalmofhurtminds]

My favorite was the trend of 70% chronic adjustment disorder. What a strange burn.

 

[erg923]

What is a "non-organic-brain/brain condition?" Would be my question.....???

I always used to tell fellow psychologists that "TBI" (as far as I was aware) is an medical event....not a diagnosis.

When I started working at the VA (2013?), there was an integrated IDES/C&P clinics on the same campus. They did great evals, and nothing but respect to them. But, they always seemed to have a lot free-time on their hands for 2 hour lunch/PT time that I never got to experience after my first month of VA (clinical) employment.

That said, I now do my dream job/hours most days: 9-3. 2 hour lunch??? 9-4?

 

[Sanman]

I don't think we billed for C&P using clinical codes. I never coded encounters for C&Ps, anyway.

We were told that they were generally 90 min to 1 hr but we had 4 hrs total for them. In addition to the clinical interview and chart/records review, we would usually give some objective testing like the PAI or MMPI-2.

Having not done this, how did the VA track productivity for those hours?

 

[Sanman]

Random question - why do I seem to see 30% and 70% SC for PTSD so often (instead of 40% or 80%)? Is this related to how 30% and 70% bumps you up from a lower SC range? How C&P evaluates impairment due to PTSD? Me seeing patterns that aren't really there?

The few PTSD folks I see have 100% sc for PTSD. Not sure how this is determined, but I wonder if this will change given the expansion of the caregiver support program recently. That 70% sc connection will entitle someone to a significant amount of caregiver support money now.

 

[Fan_of_Meehl]

You get PTSD! and You get PTSD!

And don't forget all the derivative claims ('PTSD: the universal nexus'):

- obstructive sleep apnea secondary to PTSD
- chronic headaches secondary to PTSD
- etc., etc

 

[PsyDr]

Wouldn't 100% disabled be akin to a person in a coma?

 

[Fan_of_Meehl]

Wouldn't 100% disabled be akin to a person in a coma?

The VA organization is where logic and reason go to die.

 

[Sanman]

Wouldn't 100% disabled be akin to a person in a coma?

Haha, not quite. That is 100%sc not 100% disabled. I have people with 120%+ service connection due to multiple issues.

 

[PsychPhDone]

I've

Saw a few news stories about VA contracting out 100% of C&P exams. I know it's been in the works for sometime, but looks like it's gonna happen. Are all you VA people ready for all of the C&P exams to be done by diploma mill grads who can't find better work and are willing to either work for the low pay to do an adequate eval, or do the eval so quickly as to throw out any shred of competency and integrity they had left to pump out as many as they can to make a decent wage?

I've only worked at VAs where they're contracted out. I have zero interest in doing c&ps. Fine with me.

 

[PsychPhDone]

My favorite was the trend of 70% chronic adjustment disorder. What a strange burn.

I came here to stay exactly this!

 

[cara susanna]

Haha, chronic adjustment disorder is super weird.

Speaking of SC, did anyone else hear that they're no longer offering temporary 100% to people in residential? Which... I actually thought made sense, so to me it's strange that of all the changes they decided to make in C&P it's probably the one thing I agreed with.

 

[PsyDr]

Haha, not quite. That is 100%sc not 100% disabled. I have people with 120%+ service connection due to multiple issues.

What does the percentage refer to then?

 

[Fan_of_Meehl]

What does the percentage refer to then?

The top end of their ordinal scale for 'disability' status, as I take it. Like all systems run by idio-autocrats, VA bureaucrats have a 'number fetish' which they imagine makes them appear more sophisticated/scientific than they actually are.

 

[Fan_of_Meehl]

What does the percentage refer to then?

If you want a real deep belly-laugh, take a gander at the operational definition for '100% disability' due to a mental health condition from VBA:

"Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name."

I'd imagine that some lawyer/bureaucrat just threw together severe symptoms from a number of diagnostic categories (including schizophrenia) into one ridiculous amalgam (above).

I've seen plenty of veterans who are 100% sc for PTSD who came nowhere near exhibiting actual 'gross impairment,' 'persistent delusions/hallucinations' etc.,

'Memory loss for names of close relatives, own occupation, or own name.'

LOL, these sound more like delirium or dementia symptoms than mental health symptoms you'd see in outpatient settings.

By far, my favorite presentation to deal with is veterans arguing with me that they are in fact 'paranoid' (i.e., delusional).

 

[MAClinician]

I *think* @PsyDr was asking about service connection not the disability in his follow up question (but could totally be wrong!). My limited understanding (based on a couple of conversations with a family member who served in the military, as I’ve never had experience with the VA myself) is that the percentage is related to what the VA determined the condition be a result of active service duty. Someone could have a pre-existing condition that gets worse due to service in the military. The VA somehow determines how much active service worsened that condition to give it a percentage. On the other hand, I am guessing that loss of limb during active service because your vehicle hit an IED would be 100% SC because you had all limbs prior to serving. But would love to know more as it is an interesting topic to me (the service connected part, not the disability pay part).

 

[PsychPhDone]

I *think* @PsyDr was asking about service connection not the disability in his follow up question (but could totally be wrong!). My limited understanding (based on a couple of conversations with a family member who served in the military, as I’ve never had experience with the VA myself) is that the percentage is related to what the VA determined the condition be a result of active service duty. Someone could have a pre-existing condition that gets worse due to service in the military. The VA somehow determines how much active service worsened that condition to give it a percentage. On the other hand, I am guessing that loss of limb during active service because your vehicle hit an IED would be 100% SC because you had all limbs prior to serving. But would love to know more as it is an interesting topic to me (the service connected part, not the disability pay part).

The percentages of disability are also used in other settings, like workers compensation.

 

[PsychPhDone]

Haha, chronic adjustment disorder is super weird.

Speaking of SC, did anyone else hear that they're no longer offering temporary 100% to people in residential? Which... I actually thought made sense, so to me it's strange that of all the changes they decided to make in C&P it's probably the one thing I agreed with.

I hadn't heard that. That's really frustrating.

 

[WisNeuro]

'Memory loss for names of close relatives, own occupation, or own name.'

This is Hollywood amnesia. Dementia patients don't get like this until they are likely in their final months. I do agree that whoever put the SC operational definitions in place is obviously not a clinician. Or a grossly incompetent one.

 

[Fan_of_Meehl]

This is Hollywood amnesia. Dementia patients don't get like this until they are likely in their final months. I do agree that whoever put the SC operational definitions in place is obviously not a clinician. Or a grossly incompetent one.

Which makes the criteria for 100% service-connection all the more absurd. When the prevailing wisdom is, 'Hell...dementia patients aren't bad enough off to exhibit these symptoms that people who are '100% SC/disabled' for PTSD...or major depressive disorder...or bipolar disorder supposedly exhibit.

 

[beginner2011]

I'm curious how public healthcare functions in places like Iceland and Sweden without all this assessment and evaluation of eligibility nonsense that goes on the VA. Those assessment and billing and other administrative resources would be much better spent...you know...providing care.

 

[Therapist4Chnge]

Random question - why do I seem to see 30% and 70% SC for PTSD so often (instead of 40% or 80%)? Is this related to how 30% and 70% bumps you up from a lower SC range? How C&P evaluates impairment due to PTSD? Me seeing patterns that aren't really there?

My guess is if criteria 1 is presumed (per VA guidelines for vets who were in active conflict zones), so maybe defaults to 50% SC, and then gets adjusted up/down from there? Just a guess, as it's been a bit over a decade since I've worked in the VA.

 

[PsyDr]

@PsychPhDone I am aware of how impairment ratings function in workers comp.

I. But if I’m reading this correctly, it seems like there are two different opinions about what this number is:

A. @Sanman and @MAClinician are saying the VA percentage refers to apportionment (ie, what percent responsible)

B. @Fan_of_Meehl is saying the VA percentage refers to whole body impairment rating.

Those are VERY different things.

II) Example: let’s say there’s a neurocognitive disorder that results in a 50% whole body impairment rating, and the “SC” percentage is 50%. Let’s say 100% whole body impairment pays $2k/month.

A. If it’s Sanman’s way, and the percentage refers to apportionment, and that percentage is 50%: then the VA responsibility is for 50% of the 50% whole body impairment. So ~25% whole body impairment, or $500/month.

B. If it’s Fan of Mehl’s way, and the percentage refers to whole body impairments, and the percentage is 50%, then the VA is responsible for 50% whole body impairment. Or $1000/month.

These are two VERY different numbers.

 

[cara susanna]

I BELIEVE that the percentage refers to degree of impairment. For instance, someone with 70% has some level of impairment but can still work certain jobs, whereas someone with 100% can't work at all.

 

[AbnormalPsych]

I BELIEVE that the percentage refers to degree of impairment. For instance, someone with 70% has some level of impairment but can still work certain jobs, whereas someone with 100% can't work at all.

This was my understanding too, and the impairment occurred while they were in the military. Even if not related (e.g., prostate cancer). It has been a few years since I've been at VA and never did C&P though.

Here is some info from VA's public site:

How VA Calculates Compensation Rates

The amount of basic benefit paid ranges, depending on how disabled you are. VA makes a determination about the severity of your disability based on the evidence you submit as part of your claim, or that VA obtains from your military records. VA rates disability from 0% to 100% in 10% increments (e.g. 10%, 20%, 30% etc.). See the Combined Ratings section below for information about how VA calculates disability percentage for multiple disabilities.

You may be paid additional amounts, in certain instances, if:

• You have very severe disabilities or loss of limb(s)
• you have a spouse, child(ren), or dependent parent(s)
• you have a seriously disabled spouse

VA.gov | Veterans Affairs

Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more.

www.benefits.va.gov

 

[Fan_of_Meehl]

@PsychPhDone I am aware of how impairment ratings function in workers comp.

I. But if I’m reading this correctly, it seems like there are two different opinions about what this number is:

A. @Sanman and @MAClinician are saying the VA percentage refers to apportionment (ie, what percent responsible)

B. @Fan_of_Meehl is saying the VA percentage refers to whole body impairment rating.

Those are VERY different things.

II) Example: let’s say there’s a neurocognitive disorder that results in a 50% whole body impairment rating, and the “SC” percentage is 50%. Let’s say 100% whole body impairment pays $2k/month.

A. If it’s Sanman’s way, and the percentage refers to apportionment, and that percentage is 50%: then the VA responsibility is for 50% of the 50% whole body impairment. So ~25% whole body impairment, or $500/month.

B. If it’s Fan of Mehl’s way, and the percentage refers to whole body impairments, and the percentage is 50%, then the VA is responsible for 50% whole body impairment. Or $1000/month.

These are two VERY different numbers.


III. @Fan_of_Meehl are clinicians saying that amnesia happens in PTSD? And if so, how do they balance the requirement to report people who are unable to consent to sexual relations?

The only thing I've commented on is the absurdity of some of the criteria for 100% service-connection for mental disorders.

 

[Fan_of_Meehl]

I have to say that VA is wacky and service-connection percentages (and what they mean) is no exception.

The percentages are supposed to indicate 'degrees' of social and occupational impairment...however,

I'm pretty sure that veterans who are 'just plain ole' 100% s/c can actually be employed and have income. If you tack on other designations such as 'individual unemployability' (which you can get at a lower than 100% rating) or 'permanent and total' status, I'm not sure about whether you can work and earn over a certain amount per year.

I KNOW for a fact that I have had plenty of veterans at 70% s/c for mental disorders who were working full-time jobs with high pay and excellent benefits.

So, the percentage does not seem to correspond directly with actual degree of impairment in percentage terms. To me, they seem to operate more as ordinal designations (essentially, no disability = 0%, minimal/low disability = 30%, moderate disability = 50%, high disability = 70%, and very high disability = 100%). VBA has also published lists of 'criteria' for each of the aforementioned percentages disability but they are not disorder-specific...i.e., they just have an omnibus set of 'mental disorder' criteria regardless of whether the veteran has bipolar disorder, depression, PTSD, adjustment disorder, you name it.

Another tidbit is that 'service connection' can just mean that the mental disorder was incurred (began or significantly worsened) during the veteran's time of service--not necessarily that the mental disorder was CAUSED by an event that occurred during service. So, if someone was in the Army from ages 18 - 38 and their bipolar disorder age of onset was, say, 20 years of age (while in service), the bipolar disorder would be service-connected because of WHEN it had its onset, not WHY.

It's wacky and often not at all in line with what the public would assume or, hell, with what most veterans (who haven't navigated the system) would assume.

 

[PsychPhDone]

@PsychPhDone I am aware of how impairment ratings function in workers comp.

I. But if I’m reading this correctly, it seems like there are two different opinions about what this number is:

A. @Sanman and @MAClinician are saying the VA percentage refers to apportionment (ie, what percent responsible)

B. @Fan_of_Meehl is saying the VA percentage refers to whole body impairment rating.

Those are VERY different things.

II) Example: let’s say there’s a neurocognitive disorder that results in a 50% whole body impairment rating, and the “SC” percentage is 50%. Let’s say 100% whole body impairment pays $2k/month.

A. If it’s Sanman’s way, and the percentage refers to apportionment, and that percentage is 50%: then the VA responsibility is for 50% of the 50% whole body impairment. So ~25% whole body impairment, or $500/month.

B. If it’s Fan of Mehl’s way, and the percentage refers to whole body impairments, and the percentage is 50%, then the VA is responsible for 50% whole body impairment. Or $1000/month.

These are two VERY different numbers.

I've never heard it having to do with A. My understanding is it is B. And it has to be at least as likely or not due to military service.

The individual ratings can add up to more than 100% but I have never seen someone exceed 100 percent service connection.

 

[AcronymAllergy]

Yes, it's based on severity of impairment/disability, although with certain conditions being associated with certain minimum percentages. And the overall SC% is definitely not just an arithmetic sum of the % for each individual condition. And don't even mention the Google results you'll get on the topic.

 

[cara susanna]

I have to say that VA is wacky and service-connection percentages (and what they mean) is no exception.

The percentages are supposed to indicate 'degrees' of social and occupational impairment...however,

I'm pretty sure that veterans who are 'just plain ole' 100% s/c can actually be employed and have income. If you tack on other designations such as 'individual unemployability' (which you can get at a lower than 100% rating) or 'permanent and total' status, I'm not sure about whether you can work and earn over a certain amount per year.

I KNOW for a fact that I have had plenty of veterans at 70% s/c for mental disorders who were working full-time jobs with high pay and excellent benefits.

So, the percentage does not seem to correspond directly with actual degree of impairment in percentage terms. To me, they seem to operate more as ordinal designations (essentially, no disability = 0%, minimal/low disability = 30%, moderate disability = 50%, high disability = 70%, and very high disability = 100%). VBA has also published lists of 'criteria' for each of the aforementioned percentages disability but they are not disorder-specific...i.e., they just have an omnibus set of 'mental disorder' criteria regardless of whether the veteran has bipolar disorder, depression, PTSD, adjustment disorder, you name it.

Another tidbit is that 'service connection' can just mean that the mental disorder was incurred (began or significantly worsened) during the veteran's time of service--not necessarily that the mental disorder was CAUSED by an event that occurred during service. So, if someone was in the Army from ages 18 - 38 and their bipolar disorder age of onset was, say, 20 years of age (while in service), the bipolar disorder would be service-connected because of WHEN it had its onset, not WHY.

It's wacky and often not at all in line with what the public would assume or, hell, with what most veterans (who haven't navigated the system) would assume.

I'm pretty sure you aren't supposed to be employed while receiving VA disability if you're at 100%. Unless maybe that's just individual unemployability.

 

[WisNeuro]

I'm pretty sure you aren't supposed to be employed while receiving VA disability if you're at 100%. Unless maybe that's just individual unemployability.

Technically you aren't supposed to, but I evaluated plenty of vets who were working with 100% SC. Some were even working with caregiver support.

 

[cara susanna]

Technically you aren't supposed to, but I evaluated plenty of vets who were working with 100% SC. Some were even working with caregiver support.

Yeah, I know that plenty do - just technically you aren't supposed to.

 

[Fan_of_Meehl]

I'm pretty sure you aren't supposed to be employed while receiving VA disability if you're at 100%. Unless maybe that's just individual unemployability.

It all gets pretty esoteric but I seem to recall long conversations with the patient advocate who confirmed and could cite sources that if you're merely "100% schedular" (without individual unemployability or permanent&total status) that you could be employed---though there may have been a low limit/ceiling on how much you could bring home annually. It arose in the context of a vet who was 100% schedular and seeking IU status. But I could be wrong, my brain gets mushy trying to parse/remember the byzantine 'Alice-in-Wonderland' non-Euclidean geometry of Veterans Benefit law logic.

 

[Sanman]

Yes, it's based on severity of impairment/disability, although with certain conditions being associated with certain minimum percentages. And the overall SC% is definitely not just an arithmetic sum of the % for each individual condition. And don't even mention the Google results you'll get on the topic.

From my understanding, this is all true and I think the minimum percentages start to mess up the actual level of impairment. Several people who I see who have 100%sc are still completely functional and able to drive, but not able to hold down a job. The other issue is I have no Idea how the multiple condition arithmetic works. Why does 60% SC + 40% SC= 72% SC?

 

[WisNeuro]

From my understanding, this is all true and I think the minimum percentages start to mess up the actual level of impairment. Several people who I see who have 100%sc are still completely functional and able to drive, but not able to hold down a job. The other issue is I have no Idea how the multiple condition arithmetic works. Why does 60% SC + 40% SC= 72% SC?

I thought total SC was all in increments of 10?

 

[Sanman]

I thought total SC was all in increments of 10?

It is rounded up or down. 60+40=76 actually (sorry) which round up to 80. Check out the tables on the link below if you are bored.

VA.gov | Veterans Affairs

 

[AbnormalPsych]

#VAmath

 

[parametric]

Why do so many C&P exams from the 1990s diagnose veterans with personality disorders with very little supporting info in the note?? Seen some really incongruous diagnoses of borderline, schizoid, and antisocial PDs in particular and it doesn’t escape my attention that these seem to tend to be Black veterans... I was referred a few new therapy cases recently where their historical Psych diagnoses vs their presentation in our sessions made me go WTF.