DAV Supports H.R. 1529 and S. 777, the Veterans’ Compensation Cost-of-Living Adjustment (COLA) Act of 2023. This would increase VA compensation benefit rates for veterans and those in receipt of Dependents Indemnity Compensation (DIC).

Without annual COLAs, many disabled veterans, who sacrificed their own health and family life for the good of our nation, may not be able to maintain the quality of life they deserve. Consistent with DAV Resolution No. 102, we support H.R. 1529 and S. 777. We must ensure that veterans’ benefits keep pace for the many veterans and survivors who are on fixed incomes and largely rely on their compensation payments for basic necessities.

Please contact your Senators and Representative and urge them to co-sponsor and support the Veterans’ Compensation Cost-of-Living Adjustment Act of 2023. Thank you for standing with DAV to provide a cost-of-living increase for our nation’s service disabled veterans, their families and survivors.

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Traumatic Brain Injury (TBI) is one of the most common injuries found in former combat Veterans. In fact, health officials have noticed an uptick in TBIs in military service members who served in Iraq and Afghanistan in the past decade. This guide will break down the basics of TBIs and how the VA rates them, as well as the requirements for proving secondary service connection. It will also look at TBI trends in Veterans who served in Afghanistan and Iraq.

Understanding Traumatic Brain Injury & VA Ratings

A Traumatic Brain Injury (TBI) is a disruption of brain function resulting from a blow or jolt to the head or penetrating head injury. A closed head injury occurs when the brain is not exposed, also called non-penetrating or blunt injury. A penetrating head injury, or open head injury, occurs when an object pierces the skull and breaches the dura mater, the outermost membrane of surrounding the brain.

There are several signs and symptoms of TBI to be aware of after a head injury. These include:

• any loss of consciousness
• attention issues
• headaches
• change in vision
• dizziness
• loss of balance
• sleep disturbances
• nausea
• irritability
• word-finding difficulties
• confusion

Memory loss is the most common cognitive impairment. Some people seek treatment for a TBI when they find themselves having difficulty walking a straight line. Others look for help when they have speech issues caused by muscle weakness that causes disordered speech. TBI commonly has neurobehavioral effects like depression and personality changes, as well as chronic pain and substance abuse disorder. A neurologist can link these symptoms to a TBI, ruling out other causes.

In addition to these generalized symptoms, TBI patients commonly suffer functional vision problems. These symptoms include:

• difficulty focusing
• double vision
• difficulty reading
• sensitivity to light
• aching eyes
• loss of visual field

It’s important to note that TBI symptoms can be different in every individual. The level of severity will depend on the nature of the injury, such as whether they experienced a closed or penetrating head injury. The VA takes several factors into account when a Veteran makes a claim for a traumatic brain injury.

How Does The VA Review TBI Claims?

If you make a claim for disability compensation, it’s important to understand the VA disability rating criteria for TBI, as well as the medical evidence and symptoms that they review to arrive at the rating.

What symptoms does the VA review?

The VA evaluates TBI residual effects on current level of mental or cognitive function, emotional and behavioral function, and physical function. Through this full body review, the VA can assign a disability impairment rating.

To start, it’s important to note that the VA defines cognitive functions as memory, concentration, attention, and executive functions of the brain.

• Executive functions include abilities for goal setting, speed of information, judgment, and decision making.
• VA evaluates emotional and behavioral functions based on a diagnosis of a mental disorder.
• These may include inability to control anger, impulsiveness, and lack of initiative, inappropriate sexual activity, and poor social judgment.
• VA evaluates physical functions under the appropriate diagnosis, which may include a neurological disorder.

The severity of symptoms may fluctuate from day to day and from person to person. A TBI impairs brain function temporarily or permanently. Structural damage may or may not be detectable with current technology. Therefore, the VA has the duty to evaluate subjective symptoms as well.

You may have received a diagnosis with mild, moderate, or severe TBI close to the time of injury in service. The VA will not rate your disability based on those classifications while you were in service. Keep in mind that your disability rating is based on the current level of functioning at the time the claim is filed.

How Does The VA Rating For TBI Work?

The VA recognized the old schedule for rating brain disease due to trauma needed to be updated. In 2008, VA revised the rating schedule criteria. Where VA rated the Veteran’s TBI residuals under the old version the Veteran may request review under the new code. This is irrespective of whether his or her disability has worsened since the last review.

The VA reviews that Veteran’s rating under the new codes to see if it should give the Veteran a higher rating. In this instance, the VA will treat the claim as a claim for an increased rating. It is important to note that the VA will not assign an effective date before October 23, 2008.

To break down the numerical system of the rating, the VA evaluates TBI at 0, 10, 40, 70, and 100 percent. They recognize that there are certain cases so severe that warrant a rating higher than 100%, such as when the Veteran cannot work due to the injury. The VA would then have to consider unemployability. These ratings are called special monthly compensation (SMC). There is a specific one just for TBI called SMC-T.

In order to be eligible for SMC-T, a Veteran must show several factors:

1. The Veteran needs aid and attendance
2. Without in-home aid and attendance, the Veteran would require hospitalization, nursing home care, or another type of residential institutionalized care.
3. The Veteran doesn’t otherwise qualify for a higher level of Aid & Attendance under 38 U.S.C.S. § 1114 (R-2).

To break this down further, the VA has a special definition for “aid and attendance.” A Veteran must show that they are in need of aid and attendance by proving that they have the inability to perform specific daily functions. This includes:

• Inability to dress and undress without assistance
• Inability to stay clean and presentable without assistance
• Inability to feed themselves without assistance
• Inability to attend to the wants of nature
• Exposure to hazards and dangers incident to daily environment

If a Veteran can prove all of the above factors to be true, they may be eligible for a 100% rating or more through unemployability. This then makes them eligible for special monthly compensation for their injuries.

What About Secondary Service Connection?

When a Veteran seeks disability benefits for a TBI, it’s possible that they may also qualify for benefits for secondary service connection. This means that the Veteran has other conditions that developed as a secondary result of TBI.

Officials actually adjusted the secondary service connection regulations for TBI in 2013, connecting several illnesses to this condition. These conditions include:

• Parkinsonism (including Parkinson’s Disease) following moderate or severe TBI
• Dementias (presenile dementia of the Alzheimer’s type, frontotemporal dementia, and dementia with Lewy bodies) that develops within 15 years of moderate or severe TBI
• Unprovoked seizures following moderate or severe TBI
• Depression that manifests within three years of moderate or severe TBI or within 12 months of mild TBI
• Disease of Hormone Deficiency (resulting from hypothalamo-pituitary changes) that manifests with 12 months of moderate or severe TBI

These all can apply toward a secondary service connection claim, unless there is clear evidence to demonstrate the contrary. Since the above conditions can potentially inhibit your ability to work and perform daily functions, you might decide to seek VA evaluation for the disability.

How Does VA Determine Secondary Service Connection?

The VA determines a Veteran’s eligibility for secondary service connection based on the severity of the TBI, as well as the time between the original injury and the onset of the associated medical condition. If a Veteran meets the qualifications, meaning that the TBI was severe enough and fit within the listed time frame, they don’t need to seek a medical opinion to be eligible for benefits.

As for determining the severity of a TBI, there are several factors that the VA considers. These include structural imaging, loss of consciousness, alteration of consciousness/mental state, and post-traumatic amnesia. They also use the Glasgow coma scale in their assessment if the Veteran’s TBI resulted in a coma. Depending on the severity and combination of these factors, the VA classifies the TBI as mild, moderate, or severe. However, it’s important to note that a Veteran doesn’t need to demonstrate all of these factors to fit into one level of severity. The Veteran also would qualify for the highest level of severity if they meet the criteria for multiple levels.

Again, if the TBI is severe enough and the secondary condition appeared within the listed time frame, a private medical opinion is not necessary. However, keep in mind that it can still be helpful to gather evidence when applying for secondary service connection. And this can include past medical reports. By collecting this evidence, you are helping to ensure a more accurate VA evaluation. You can also avoid seeking a medical opinion while the evaluation is ongoing.

Acceptable Evidence for VA TBI Claim

Examples of acceptable evidence may include medical reports from past exams, statements from the Veteran, service treatment records that followed the TBI, and witness statements regarding the original injury. All of these pieces of evidence should be from the time of the TBI or shortly after.

To summarize, some Veterans may be eligible for benefits based on the original TBI and secondary service condition. Since the combination of these qualifications can be complicated, it’s important to gather as much evidence as possible and work with a reputable lawyer to put together a case. Doing so will create a stronger claim and for disability benefits.

Traumatic Brain Injury Increases inIraq &Afghanistan Veterans

More than 19,000 service members were diagnosed with mild traumatic brain injury, or concussion, in 2010, according to the Defense Centers of Excellence website. The signature injury of the war in Iraq and Afghanistan is residuals of TBI. The increase is linked to the common use of roadside improvised explosive devices or IEDs, and the resulting blasts.

The VA has made brain injuries a leadership priority. They recognize the critical challenge of TBI and concussion as signature injuries of modern combat and one of the leading combat injuries in recent years [American Forces Press Service, March 14, 2011]. Studies have estimated that about 20% of soldiers returning from Iraq and Afghanistan have suffered at least a mild traumatic brain injury while deployed. Of those, anywhere between 5% to nearly 50% may suffer both post traumatic stress disorder (PTSD) and lingering problems from traumatic brain injuries as well [ProPublica, and Daniel Zwerdling, NPR March 13, 2012].

What Has Caused These TBIs?

Common causes of TBI or concussion in active duty include blasts, vehicle collisions, or blows to the head. There are four categories of TBI including mild, moderate, severe and penetrating. A mild TBI, which is also known as a concussion, is the most common form of TBI. Although most people recover from mild TBI, the outcome of mild-penetrating TBIs can range from complete recovery to permanent disability or death.

Scientists at the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, are studying the effects of TBIs on the brain and the brain’s response to injury. There is more than meets the eye following even a mild traumatic brain injury. Oftentimes, initial scans do not reveal any physical damage to the brain tissue. However, recent studies by NINDS have shown that there may be therapeutic modalities to decrease the brain damage of TBI if treatment is rendered within hours after the injury. Unfortunately, a service member in the battlefield is not afforded immediate medical treatment. More often than not, a Veteran may not seek treatment for TBI symptoms until discharge from service. This may be in part due to lack of comprehension about the signs and symptoms of TBI not only by the Veteran but oftentimes the VA medical community.

Veterans may be entitled to disability benefits if they can prove that the injury occurred during service, and that they have a current disability linked to the injury. They may also be eligible based on secondary service connection regulations. If you are interested in pursuing benefits based on your injury or medical condition, a Veterans disability law firm can work with you to interpret the VA’s TBI rating system and requirements. They can also work with you to collect medical evidence, make a claim, and appeal your case if necessary.

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Traumatic Brain Injury (TBI) is one of the most common injuries found in former combat Veterans. In fact, health officials have noticed an uptick in TBIs in military service members who served in Iraq and Afghanistan in the past decade. This guide will break down the basics of TBIs and how the VA rates them, as well as the requirements for proving secondary service connection. It will also look at TBI trends in Veterans who served in Afghanistan and Iraq.

Understanding Traumatic Brain Injury & VA Ratings

A Traumatic Brain Injury (TBI) is a disruption of brain function resulting from a blow or jolt to the head or penetrating head injury. A closed head injury occurs when the brain is not exposed, also called non-penetrating or blunt injury. A penetrating head injury, or open head injury, occurs when an object pierces the skull and breaches the dura mater, the outermost membrane of surrounding the brain.

There are several signs and symptoms of TBI to be aware of after a head injury. These include:

• any loss of consciousness
• attention issues
• headaches
• change in vision
• dizziness
• loss of balance
• sleep disturbances
• nausea
• irritability
• word-finding difficulties
• confusion

Memory loss is the most common cognitive impairment. Some people seek treatment for a TBI when they find themselves having difficulty walking a straight line. Others look for help when they have speech issues caused by muscle weakness that causes disordered speech. TBI commonly has neurobehavioral effects like depression and personality changes, as well as chronic pain and substance abuse disorder. A neurologist can link these symptoms to a TBI, ruling out other causes.

In addition to these generalized symptoms, TBI patients commonly suffer functional vision problems. These symptoms include:

• difficulty focusing
• double vision
• difficulty reading
• sensitivity to light
• aching eyes
• loss of visual field

It’s important to note that TBI symptoms can be different in every individual. The level of severity will depend on the nature of the injury, such as whether they experienced a closed or penetrating head injury. The VA takes several factors into account when a Veteran makes a claim for a traumatic brain injury.

How Does The VA Review TBI Claims?

If you make a claim for disability compensation, it’s important to understand the VA disability rating criteria for TBI, as well as the medical evidence and symptoms that they review to arrive at the rating.

What TBI symptoms does the VA review?

The VA evaluates TBI symptoms as residual effects on current level of mental or cognitive function, emotional and behavioral function, and physical function. Through this full-body review, the VA can assign a disability impairment rating.

To start, it’s important to note that the VA defines cognitive functions as memory, concentration, attention, and executive functions of the brain.

• Executive functions include abilities for goal setting, speed of information, judgment, and decision making.
• VA evaluates emotional and behavioral functions based on a diagnosis of a mental disorder.
  • These may include inability to control anger, impulsiveness, and lack of initiative, inappropriate sexual activity, and poor social judgment.
• VA evaluates physical functions under the appropriate diagnosis, which may include a neurological disorder.

The severity of TBI symptoms may fluctuate from day to day and from person to person. A TBI impairs brain function temporarily or permanently. Structural damage may or may not be detectable with current technology. Therefore, the VA has the duty to evaluate subjective symptoms as well.

You may have received a diagnosis with mild, moderate, or severe TBI close to the time of injury in service. The VA will not rate your disability based on those classifications while you were in service. Keep in mind that your disability rating is based on the current level of functioning at the time the claim is filed.

How Does the VA Rating for TBI Work?

The VA recognized the old schedule for rating brain disease due to trauma needed to be updated. In 2008, VA revised the rating schedule criteria. Where VA rated the Veteran’s TBI residuals under the old version the Veteran may request review under the new code. This is irrespective of whether his or her disability has worsened since the last review.

The VA reviews that Veteran’s rating under the new codes to see if it should give the Veteran a higher rating. In this instance, the VA will treat the claim as a claim for an increased rating. It is important to note that the VA will not assign an effective date before October 23, 2008.

To break down the numerical system of the rating, the VA evaluates TBI at 0, 10, 40, 70, and 100 percent. They recognize that there are certain cases so severe that warrant a rating higher than 100%, such as when the Veteran cannot work due to the injury. The VA would then have to consider unemployability. These ratings are called special monthly compensation (SMC). There is a specific one just for TBI called SMC-T.

In order to be eligible for SMC-T, a Veteran must show several factors:

• The Veteran needs aid and attendance
• Without in-home aid and attendance, the Veteran would require hospitalization, nursing home care, or another type of residential institutionalized care.
• The Veteran doesn’t otherwise qualify for a higher level of Aid & Attendance under 38 U.S.C.S. § 1114 (R-2).

To break this down further, the VA has a special definition for “aid and attendance.” A Veteran must show that they are in need of aid and attendance by proving that they have the inability to perform specific daily functions. This includes:

• Inability to dress and undress without assistance
• Inability to stay clean and presentable without assistance
• Inability to feed themselves without assistance
• Inability to attend to the wants of nature
• Exposure to hazards and dangers incident to daily environment

If a Veteran can prove all of the above factors to be true, they may be eligible for a 100% rating or more through unemployability. This then makes them eligible for special monthly compensation for their injuries.

What About Secondary Service Connection?

When a Veteran seeks disability benefits for a TBI, it’s possible that they may also qualify for benefits for secondary service connection. This means that the Veteran has other conditions that developed as a secondary result of TBI.

Officials actually adjusted the secondary service connection regulations for TBI in 2013, connecting several illnesses to this condition. These conditions include:

• Parkinsonism (including Parkinson’s Disease) following moderate or severe TBI
• Dementias (presenile dementia of the Alzheimer’s type, frontotemporal dementia, and dementia with Lewy bodies) that develops within 15 years of moderate or severe TBI
• Unprovoked seizures following moderate or severe TBI
• Depression that manifests within three years of moderate or severe TBI or within 12 months of mild TBI
• Disease of Hormone Deficiency (resulting from hypothalamo-pituitary changes) that manifests with 12 months of moderate or severe TBI

These all can apply toward a secondary service connection claim, unless there is clear evidence to demonstrate the contrary. Since the above conditions can potentially inhibit your ability to work and perform daily functions, you might decide to seek VA evaluation for the disability.

How Does VA Determine Secondary Service Connection?

The VA determines a Veteran’s eligibility for secondary service connection based on the severity of the TBI, as well as the time between the original injury and the onset of the associated medical condition. If a Veteran meets the qualifications, meaning that the TBI was severe enough and fit within the listed time frame, they don’t need to seek a medical opinion to be eligible for benefits.

As for determining the severity of a TBI, there are several factors that the VA considers. These include structural imaging, loss of consciousness, alteration of consciousness/mental state, and post-traumatic amnesia. They also use the Glasgow coma scale in their assessment if the Veteran’s TBI resulted in a coma. Depending on the severity and combination of these factors, the VA classifies the TBI as mild, moderate, or severe. However, it’s important to note that a Veteran doesn’t need to demonstrate all of these factors to fit into one level of severity. The Veteran also would qualify for the highest level of severity if they meet the criteria for multiple levels.

Again, if the TBI is severe enough and the secondary condition appeared within the listed time frame, a private medical opinion is not necessary. However, keep in mind that it can still be helpful to gather evidence when applying for secondary service connection. And this can include past medical reports. By collecting this evidence, you are helping to ensure a more accurate VA evaluation. You can also avoid seeking a medical opinion while the evaluation is ongoing.

Acceptable Evidence for VA TBI Claim

Examples of acceptable evidence may include medical reports from past exams, statements from the Veteran, service treatment records that followed the TBI, and witness statements regarding the original injury. All of these pieces of evidence should be from the time of the TBI or shortly after.

To summarize, some Veterans may be eligible for benefits based on the original TBI and secondary service condition. Since the combination of these qualifications can be complicated, it’s important to gather as much evidence as possible and work with a reputable lawyer to put together a case. Doing so will create a stronger claim and for disability benefits.

Traumatic Brain Injury Increases in Iraq & Afghanistan Veterans

More than 19,000 service members were diagnosed with mild traumatic brain injury, or concussion, in 2010, according to the Defense Centers of Excellence website. The signature injury of the war in Iraq and Afghanistan is residuals of TBI. The increase is linked to the common use of roadside improvised explosive devices or IEDs, and the resulting blasts.

The VA has made brain injuries a leadership priority. They recognize the critical challenge of TBI and concussion as signature injuries of modern combat and one of the leading combat injuries in recent years [American Forces Press Service, March 14, 2011]. Studies have estimated that about 20% of soldiers returning from Iraq and Afghanistan have suffered at least a mild traumatic brain injury while deployed. Of those, anywhere between 5% to nearly 50% may suffer both post-traumatic stress disorder (PTSD) and lingering problems from traumatic brain injuries as well [ProPublica, and Daniel Zwerdling, NPR March 13, 2012].

What Has Caused These TBIs?

Common causes of TBI or concussion in active duty include blasts, vehicle collisions, or blows to the head. There are four categories of TBI including mild, moderate, severe and penetrating. A mild TBI, which is also known as a concussion, is the most common form of TBI. Although most people recover from mild TBI, the outcome of mild-penetrating TBIs can range from complete recovery to permanent disability or death.

Scientists at the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, are studying the effects of TBIs on the brain and the brain’s response to injury. There is more than meets the eye following even a mild traumatic brain injury. Oftentimes, initial scans do not reveal any physical damage to the brain tissue. However, recent studies by NINDS have shown that there may be therapeutic modalities to decrease the brain damage of TBI if treatment is rendered within hours after the injury. Unfortunately, a service member in the battlefield is not afforded immediate medical treatment. More often than not, a Veteran may not seek treatment for TBI symptoms until discharge from service. This may be in part due to lack of comprehension about the signs and symptoms of TBI not only by the Veteran but oftentimes the VA medical community.

Veterans may be entitled to disability benefits if they can prove that the injury occurred during service, and that they have a current disability linked to the injury. They may also be eligible based on secondary service connection regulations. If you are interested in pursuing benefits based on your injury or medical condition, a Veteran’s disability law firm can work with you to interpret the VA’s TBI rating system and requirements. They can also work with you to collect medical evidence, make a claim, and appeal your case if necessary.

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Veterans Affairs officials are confident they will be able to reduce the backlog of hundreds of thousands of compensation and pension exams by this fall, but watchdog groups are expressing more skepticism that such a goal is realistic.

“Yes, they have increased examiners across the nation, but the new alternate methods tend not to be as impactful as Veterans Benefits Administration officials had hoped,” Brent Arronte, deputy assistant at the VA Office of the Inspector General, told lawmakers during a House hearing on Tuesday.

“My fear right now in watching these numbers every month is that we might be getting into a situation where they’re just treading water.”

Compensation and pension exams are a key part of the process for Veterans to receive disability benefits. In most cases before payouts begin, VA requires some type of review by a medical expert to confirm a Veteran’s injuries and the severity of its impact.

All compensation and pension exams were suspended for two months in spring 2020 in response to the coronavirus pandemic. Veterans Affairs officials said that pause alone added about 200,000 exams to the backlog of unmet requests.

At the start of March, about 357,000 exam requests were pending, nearly three times the 130,000 pending at the end of February 2020.

Veterans Affairs officials have repeatedly promised that Veterans awaiting exams will not be punished for the delays, and will receive appropriate back benefits once their cases are approved. But outside advocates have noted that still means months of waiting for Veterans to have their cases finalized before those payouts begin.

David McLenachen, executive director of the Veterans Benefit Administration’s Medical Disability Examination Office, said officials hope to bring down the backlog to pre-pandemic levels by the end of this fiscal year, Sept. 30.

He said exam operations are returning to normal, and outside contractors have dramatically ramped up their workload in recent months. However, the department still needs to process about 8,000 more exams a week than they are today in order to reach the fall goal.

On Tuesday, Arronte said that online health meetings and other alternatives to in-person exams have helped efforts to address the backlog. But they still make up only a small fraction of total exams, meaning their impact thus far has been limited.

And officials from the Government Accountability Office this week released a new analysis of the backlog and chastised VA leaders for not developing a clear, long-term plan to address the issue.

McLenachen dismissed that criticism.

“I would love to do ordinary business planning and forecast out when certain events would happen and when we can achieve the goal,” he told lawmakers. “But simply stating that we need to plan for when exactly certain events will happen between now and the goal that we’ve established is a very difficult thing to do during the pandemic.”

However, members of the House committee said they have concerns about that approach.

“There should be a written plan,” said Rep. Elaine Luria, D-Va., chairwoman of the House Veterans’ Affairs Committee’s panel on disability assistance. “You can always use it as a planning tool and deviate from it as needed. But I think a written plan would help all of the stakeholders and the Veterans understand the timeline for reducing this backlog.”

Veterans groups said the challenge facing VA isn’t just the immediate backlog total, but the potential of what it can become.

The department already has about 30,000 new cases enter the system each month. But with new changes mandated by Congress in recent years to presumptive conditions for tens of thousands of Vietnam Veterans, those numbers could increase. Future approval of other toxic exposure benefits issues like burn pit exposure could lead to even higher levels.

“The moment VA suspended all exams an unavoidable backlog began building,” said Ryan Gallucci, director of the National Veterans Service at the Veterans of Foreign Wars. “Rebuilding from this pandemic will present challenges to everyone involved in the VA claims process, and we must all work to ensure Veterans do not slip through the cracks.”

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A Texas woman was sentenced to 18 months in prison today for her role in a $5.5 million scheme to overbill the U.S. Department of Labor Office of Workers’ Compensation Program for physical therapy and other services.

Acting Assistant Attorney General Brian C. Rabbitt of the Justice Department’s Criminal Division, U.S. Attorney Erin Nealy Cox of the Northern District of Texas, Special Agent in Charge Robert Bourbon of the U.S. Department of Justice Office of the Inspector General’s (DOJ-OIG) Dallas Field Office, Special Agent in Charge Steven Grell of the U.S. Department of Labor Office of Inspector General’s (DOL-OIG) Dallas Regional Office, Special Agent in Charge Scott Pierce of the U.S. Postal Service Office of Inspector General’s (USPS-OIG) Southern Area Field Office, Acting Special Agent in Charge Patrick Roche of the U.S. Department of Veterans Affairs Office of Inspector General’s (VA-OIG) Criminal Investigations Division South Central Field Office, and Special Agent in Charge Ray Rayos of the U.S. Army Criminal Investigation Command's Major Procurement Fraud Unit (MPFU) Southwest Fraud Field Office made the announcement.

Melissa Sumerour, 49, of Lorena, Texas, was sentenced by U.S. District Judge Karen Gren Scholer of the Northern District of Texas to 18 in prison followed by three years of supervised release. After a trial in December 2019, Sumerour was convicted of six counts of health care fraud.

According to evidence presented at trial, from approximately January 2011 to March 2017, Sumerour engaged in a scheme to defraud the DOL’s Office of Workers’ Compensation Program by overbilling for physical therapy. The evidence established that the fraud, in which Sumerour billed for more physical therapy than was provided, cost the Office of Workers’ Compensation Program in excess of $5.5 million.

One other defendant has been charged in this matter. Latosha Morgan, 42, of Grand Prairie, Texas, pleaded guilty and is awaiting sentencing.  

This case was investigated by DOJ-OIG, DOL-OIG, USPS-OIG, VA-OIG, and Army CID-MPFU. Trial Attorneys Brynn Schiess and Amy Markopoulos of the Criminal Division’s Fraud Section are prosecuting the case.

The Fraud Section leads the Medicare Fraud Strike Force. Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged more than 4,200 defendants who have collectively billed the Medicare program for nearly $19 billion. In addition, the HHS Centers for Medicare & Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The year 2020 marks the 150th anniversary of the Department of Justice. Learn more about the history of our agency at www.Justice.gov/Celebrating150Years.

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Despite concerns from lawmakers, Veterans Affairs officials are moving ahead with plans to outsource nearly all compensation and pension exams in coming months, a move they believe will improve service for Veterans.

“This is just the evolution of the process,” said Under Secretary for Benefits Paul Lawrence in an interview with Military Times last week. “Right now, contractors are already doing the bulk of them. We think the value of having contractors available to do them is flexibility and the ability to surge.”

The compensation and pension exams are a key part of the process for Veterans to receive disability benefits. In most cases before payouts begin, VA requires some type of review by a medical expert to confirm a Veteran’s injuries and the severity of its impact.

Before the coronavirus pandemic, about 25 percent of those exams were conducted at VA medical centers or health clinics. When many of those were partially shuttered due to virus prevention efforts, the backlog of C&P exams swelled to more than 350,000.

Lawrence said as of the start of November, the Veterans Benefits Administration has erased most of that backlog and now sits at pre-pandemic service levels. Only about 15 percent of the exams are handled by VA health staff now, with the rest outsourced to private-sector contractors.

He sees that remaining the norm as the department moves forward.

“The Veterans Health Administration is still dealing with the Covid-19 pandemic, so the question is what is the best use of those doctors in terms of helping Veterans?” he said. “That’s the kind of balancing act we’re looking at.”

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Veterans with residuals of Traumatic Brain Injury (TBI) can receive additional benefits if they are housebound. The rating and compensation criteria fall under SMC (S). If the Veteran is currently at a 100% va disability rate, and VA finds that the Veteran is housebound, they will pay the Veteran at the 100% rate with an additional $375 per month.

In order to be eligible for housebound benefits, the Veteran must have:

• A single service-connected disability rated as totally disabling and additional service-connected disabilities that are independently rated at 60 percent.
  • Example: a Veteran who has been service-connected for his back condition at 100% and has been rated 60% for PTSD.

OR

• A single service-connected disability rated as totally disabling, and (Veteran must) be permanently housebound because of the service-connected disability or disabilities.
  • Example: a Veteran who has been awarded TDIU for his service-connected TBI and has been determined to be housebound due to his condition.

A Veteran is considered to be housebound when:

• Veteran is substantially confined to his/her dwelling as a direct result of service-connected disabilities
• It is reasonably certain that the disability will persist throughout his/her lifetime

However, according to the regulations, the Veteran does not have to be completely confined to his/her home to satisfy the requirement of being “substantially” confined to the dwelling or immediate premises. The Court of Veterans Appeals has held that leaving one’s house for medical purposes cannot, by itself, constitute a basis for finding that one is not substantially confined. In addition, the Veteran’s disabilities need not be rated permanent in order to receive this benefit.

Basic SMC-S Rates for Veterans without Children

Basic SMC-S Rates with Dependents, Including Children

Source: VA.Gov

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