Will VA pay for SC emergency room visit?

Discussion in 'General Medical' started by janderson06, Apr 14, 2007.

  1. janderson06

    janderson06 New Member

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    Back in January my wife had to take me to a private hospital's emergency room because of a service connected medical problem. The nearest VA medical facility is about 60 miles from my home. I was admitted to the private hospital and stayed there for four nights then transferred to the VA. My wife contacted the VA the day after I was admitted (I was admitted on a Thursday and she called them Friday morning). The VA stated they would transfer me on Monday and they did follow through.

    My question is will the VA pay my private hospital bill? If so, what do I need to do? I have just started to receive bills from the hospital and I am looking at about $13,000. Some of my vet friends told me the VA would cover it, but they can't tell me how to start the process.

    Thanks for any input! Sincerely,
    Joe Anderson
  2. Vike17

    Vike17 New Member

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    Joe,

    Since your wife notified the VA within 72 hours of your admission to the private hospital for an emergency, you shouldn't have a problem with VHA picking up the tab.

    §17.52 Hospital care and medical services in non-VA facilities.
    (a) When VA facilities or other government facilities are not capable of furnishing economical hospital care or medical services because of geographic inaccessibility or are not capable of furnishing care or services required, VA may contract with non-VA facilities for care in accordance with the provisions of this section. When demand is only for infrequent use, individual authorizations may be used. Care in public or private facilities, however, subject to the provisions of §17.53 through f, will only be authorized, whether under a contract or an individual authorization, for:
    (1) Hospital care or medical services to a veteran for the treatment of:

    (i) A service-connected disability; or
    (ii) A disability for which a veteran was discharged or released from the active military, naval, or air service or
    (iii) A disability of a veteran who has a total disability permanent in nature from a service-connected disability, or
    (iv) For a disability associated with and held to be aggravating a service-connected disability, or
    (v) For any disability of a veteran participating in a rehabilitation program under 38 U.S.C. ch. 31 and when there is a need for hospital care or medical services for any of the reasons enumerated in §17.48(j). (Authority: 38 U.S.C. 1703, 3104; sec. 101, Pub. L. 96-466; sec. 19012, Pub. L. 99-272)
    (2) Medical services for the treatment of any disability of:
    (i) A veteran who has a service-connected disability rated at 50 percent or more,
    (ii) A veteran who has received VA inpatient care for treatment of nonservice-connected conditions for which treatment was begun during the period of inpatient care. The treatment period (to include care furnished in both facilities of VA and non-VA facilities or any combination of such modes of care) may not continue for a period exceeding 12 months following discharge from the hospital except when it is determined that a longer period is required by virtue of the disabilities being treated, and
    (iii) A veteran of the Mexican border period or World War I or who is in receipt of increased pension or additional compensation based on the need for aid and attendance or housebound benefits when it has been determined based on an examination by a physician employed by VA (or, in areas where no such physician is available, by a physician carrying out such function under a contract or fee arrangement), that the medical condition of such veteran precludes appropriate treatment in VA facilities; (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. 99-272)
    (3) Hospital care or medical services for the treatment of medical emergencies which pose a serious threat to the life or health of a veteran receiving hospital care or medical services in a facility over which the Secretary has direct jurisdiction or government facility with which the Secretary contracts, and for which the facility is not staffed or equipped to perform. and transfer to a public or private hospital which has the necessary staff or equipment is the only feasible means of providing the necessary treatment, until such time following the furnishing of care in the non-VA facility as the veteran can be safely transferred to a VA facility; (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. 99-272)
    (4) Hospital care for women veterans; (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. 99-272)
    (5) Through September 30, 1988, hospital care or medical services that will obviate the need for hospital admission for veterans in the Commonwealth of Puerto Rico, except that the dollar expenditure in Fiscal year 1986 cannot exceed 85% of the Fiscal year 1985 obligations, in Fiscal year 1987 the dollar expenditure cannot exceed 50% of the Fiscal year 1985 obligations and in Fiscal year 1988 the dollar expenditure cannot exceed 25% of the Fiscal year 1985 obligations. (Authority: 38 U.S.C. 1703; sec. 102, Pub. L. 99-166; sec. 19012, Pub. L. 99-272)
    (6) Hospital care or medical services that will obviate the need for hospital admission for veterans in Alaska, Hawaii, Virgin Islands and other territories of the United States except that the annually determined hospital patient load and incidence of the furnishing of medical services to veterans hospitalized or treated at the expense of VA in government and non-VA facilities in each such State or territory shall be consistent with the patient load or incidence of the provision of medical services for veterans hospitalized or treated by VA within the 48 contiguous States. (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. 99-272)
    (7) Outpatient dental services and treatment, and related dental appliances, for a veteran who is a former prisoner of war and was detained or interned for a period of not less that 181 days. (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. 99-272)
    (8) Hospital care or medical services for the treatment of medical emergencies which pose a serious threat to the life or health of a veteran which developed during authorized travel to the hospital, or during authorized travel after hospital discharge preventing completion of travel to the originally designated point of return (and this will encompass any other medical services necessitated by the emergency, including extra ambulance or other transportation which may also be furnished at VA expense. (Authority: 38 U.S.C. 1701(5))
    (9) Diagnostic services necessary for determination of eligibility for, or of the appropriate course of treatment in connection with, furnishing medical services at independent VA outpatient clinics to obviate the need for hospital admission. (Authority: 38 U.S.C. 1703; sec. 19012, Pub. L. 99-272)
    (10) For any disability of a veteran receiving VA contract nursing home care. The veteran is receiving contract nursing home care and requires emergency treatment in non-VA facilities. (Authority: 38 U.S.C. 1703(a))
    (11) For completion of evaluation for observation and examination (O&E) purposes, clinic directors or their designees will authorize necessary diagnostic services at non-VA facilities (on an inpatient or outpatient basis) in order to complete requests from VA Regional Offices for O&E of a person to determine eligibility for VA benefits or services.

    (b) The Under Secretary for Health shall only furnish care and treatment under paragraph (a) of this section to veterans described in §17.47(d).
    (1) To the extent that resources are available and are not otherwise required to assure that VA can furnish needed care and treatment to veterans described in §17.47(a) and (c), and
    (2) If the veteran agrees to pay the United States an amount as determined in §17.48(e). (Authority: 38 U.S.C. 1703, 1710 and 1712; sec. 19011-19012, Pub. L. 99-272)
    [51 FR 25066, July 10, 1986, as amended at 53 FR 32391, Aug. 25, 1988; 54 FR 53057, Dec. 27, 1989; 58 FR 32446, June 10, 1993. Redesignated and amended at 61 FR 21965, 21966, May 13, 1996; 62 FR 17072, Apr. 9, 1997]


    §17.53 Limitations on use of public or private hospitals.
    The admission of any patient to a private or public hospital at Department of Veterans Affairs expense will only be authorized if a Department of Veterans Affairs medical center or other Federal facility to which the patient would otherwise be eligible for admission is not feasibly available. A Department of Veterans Affairs facility may be considered as not feasibly available when the urgency of the applicant’s medical condition, the relative distance of the travel involved, or the nature of the treatment required makes it necessary or economically advisable to use public or private facilities. In those instances where care in public or private hospitals at Department of Veterans Affairs expense is authorized because a Department of Veterans Affairs or other Federal facility was not feasibly available, as defined in this section, the authorization will be continued after admission only for the period of time required to stabilize or improve the patient’s condition to the extent that further care is no longer required to satisfy the purpose for which it was initiated.

    [39 FR 17223, May 14, 1974, as amended at 47 FR 58248, Dec. 30, 1982. Redesignated at 61 FR 21965, May 13, 1996]


    §17.54 Necessity for prior authorization.
    (a) The admission of a veteran to a non-Department of Veterans Affairs hospital at Department of Veterans Affairs expense must be authorized in advance. In the case of an emergency which existed at the time of admission, an authorization may be deemed a prior authorization if an application, whether formal or informal, by telephone, telegraph or other communication, made by the veteran or by others in his or her behalf is dispatched to the Department of Veterans Affairs (1) for veterans in the 48 contiguous States and Puerto Rico, within 72 hours after the hour of admission, including in the computation of time Saturday, Sunday and holidays, or (2) for veterans in a noncontiguous State, territory or possession of the United States (not including Puerto Rico) if facilities for dispatch of application as described in this section are not available within the 72-hour period, provided the application was filed within 72 hours after facilities became available.
    (b) When an application for admission by a veteran in one of the 48 contiguous States in the United States or in Puerto Rico has been made more than 72 hours after admission, or more than 72 hours after facilities are available in a noncontiguous State, territory of possession of the United States, authorization for continued care at Department of Veterans Affairs expense shall be effective as of the postmark or dispatch date of the application, or the date of any telephone call constituting an informal application.

    [42 FR 55212, Oct. 14, 1977. Redesignated at 61 FR 21965, May 13, 1996]


    Vike 17
  3. janderson06

    janderson06 New Member

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    Thanks!

    Thanks Vike 17 for your quick and thorough advice. I only hope my wife's call to the VA will be considered an application. I wonder if perhaps you, or anyone else, may know the name and/or number of the application form? I will try to look it up and I will post it here if I find it in case anyone else runs into this situation.

    Thanks Again!
    Joe Anderson
  4. janderson06

    janderson06 New Member

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    §17.1002 Substantive conditions for payment or reimbursement.

    Payment or reimbursement under 38 U.S.C. 1725 for emergency services may be
    made only if all of the following conditions are met:

    (a) The emergency services were provided in a hospital emergency department
    or a similar facility held out as providing emergency care to the public;

    (b) The claim for payment or reimbursement for the initial evaluation and
    treatment is for a condition of such a nature that a prudent layperson would
    have reasonably expected that delay in seeking immediate medical attention
    would have been hazardous to life or health (this standard would be met if
    there were an emergency medical condition manifesting itself by acute
    symptoms of sufficient severity (including severe pain) that a prudent
    layperson who possesses an average knowledge of health and medicine could
    reasonably expect the absence of immediate medical attention to result in
    placing the health of the individual in serious jeopardy, serious impairment
    to bodily functions, or serious dysfunction of any bodily organ or part);

    (c) A VA or other Federal facility/provider was not feasibly available and
    an attempt to use them beforehand would not have been considered reasonable
    by a prudent layperson (as an example, these conditions would be met by
    evidence establishing that a veteran was brought to a hospital in an
    ambulance and the ambulance personnel determined that the nearest available
    appropriate level of care was at a non-VA medical center);

    (d) The claim for payment or reimbursement for any medical care beyond the
    initial emergency evaluation and treatment is for a continued medical
    emergency of such a nature that the veteran could not have been safely
    discharged or transferred to a VA or other Federal facility (the medical
    emergency lasts only until the time the veteran becomes stabilized);

    (e) At the time the emergency treatment was furnished, the veteran was
    enrolled in the VA health care system and had received medical services
    under authority of 38 U.S.C. chapter 17 within the 24-month period preceding
    the furnishing of such emergency treatment;

    (f) The veteran is financially liable to the provider of emergency treatment
    for that treatment;

    (g) The veteran has no coverage under a health-plan contract for payment or
    reimbursement, in whole or in part, for the emergency treatment (this
    condition cannot be met if the veteran has coverage under a health-plan
    contract but payment is barred because of a failure by the veteran or the
    provider to comply with the provisions of that health-plan contract, e.g.,
    failure to submit a bill or medical records within specified time limits, or
    failure to exhaust appeals of the denial of payment);




    (h) If the condition for which the emergency treatment was furnished was
    caused by an accident or work-related injury, the claimant has exhausted
    without success all claims and remedies reasonably available to the veteran
    or provider against a third party for payment of such treatment; and the
    veteran has no contractual or legal recourse against a third party that
    could reasonably be pursued for the purpose of extinguishing, in whole or in
    part, the veteran’s liability to the provider; and

    (i) The veteran is not eligible for reimbursement under 38 U.S.C. 1728 for
    the emergency treatment provided (38 U.S.C. 1728 authorizes VA payment or
    reimbursement for emergency treatment to a limited group of veterans,
    primarily those who receive emergency treatment for a service-connected
    disability). (Authority: 38 U.S.C. 1725)


    [66 FR 36470, July 12, 2001, as amended at 68 FR 3404, Jan. 24, 2003]


    Supplement Highlights reference: 14(1)

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