09/09/2019: Courts rule that VA should pay as secondary on Emergent Claims
On September 9, 2019, the United States Court of Appeals for Veterans Claims invalidated federal regulations related to reimbursement of a Veteran’s cost of emergency medical care at non-VA facilities. Specifically, the Court held that the VA must reimburse Veterans for out-of-pocket emergency medical expenses not covered by the Veteran’s health insurance contract (e.g., deductible and coinsurance amounts).
The Court further indicated that it was Congress’s intent that the VA step in as a secondary payer when other health care insurers cover only a portion of the cost of the Veteran’s emergency treatment (the Staab Rule). The Court held that the VA’s denial of emergency service claims on the ground that the expenses are part of a deductible or coinsurance was invalid. The Court has ordered the VA to re-adjudicate these inappropriately denied claims for reimbursement.
Although the VA’s response to this ruling has been inconsistent, we believe that hospitals alert business office staff regarding the ability to bill the VA as secondary for emergency services when the veteran is assigned a coinsurance or deductible amount. We further recommended that hospitals develop an appeal letter template for instances when the VA has wrongfully denied reimbursement of such claims because the patient had “other health insurance.”
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