Can You Get a VA Rating Without a C&P Exam?
Compensation and pension exams are an important part of the disability claims process through the U.S Department of Veterans Affairs. This medical exam can often make or break your claim for service connection. C&P examiners, who are typically VA doctors, assess a veterans injury or illness as it relates to the veteran’s claim for disability benefits, and the appointments typically occur at a VA medical center.
But are these exams always necessary? While C&P exams can provide key medical evidence and help a veteran obtain appropriate disability compensation, there are instances when an exam might be unnecessary. Here’s what disabled veterans should know.
Do You Really NEED a C&P exam?
Every veteran who is not rated as permanent and totally disabled is subject to C&P re-examinations in the future. This is part of the exam processes under the VA. Many are prescheduled, but some can be triggered by changes in symptoms noted in medical records. However, the VA has specific protocols in place to determine if those exams are needed. Unless already scheduled as a standard review (such as a 5 year review which is required to be identified on a rating decision code sheet), VA policy requires that a pre-exam review must be conducted before a C&P is ordered to determine if the veteran meets criteria for a new exam.
The purpose of the pre-exam is to justify the cost of the C&P exam. A review of the veteran’s records can show if the veteran is still experiencing similar symptoms, obtaining consistent treatment, and justifying the current rating that they are awarded. It is only when the records show that the rating is no longer justified that an exam should be ordered. And this works both ways, for reducing or increasing a rating.
For example, a veteran rated at 30% for PTSD but records show the veteran has been hospitalized several times in the last few years for suicidal thoughts; that warrants and exam for an increased rating. Another example is when a veteran has been rated at 100% for a malignant cancer. The 100% va disability will be granted for up to six months after successful treatment, and then the rating may be decreased if the cancer is no longer malignant and the residuals do not warrant a 100% rating.
However, as everyone knows, the VA rarely orders a C&P exam for increased rating, and often orders them to decrease ratings when there is no justifiable reason in the veteran’s files to do so. Wonder why?
Found Unwarranted Expenses
In a recent Oversight Report written by the Veterans Affairs Office of Inspector General, it was found that the VA spent over $10 million dollars between March and August 2017 )a five month period) on unwarranted C&P reexaminations of veterans. The OIG’s office estimate that over $100 million would be wasted on unnecessary exams over the next five years if VBA staff continues to requested review exams without using proper discretion (my math comes out to $127 million dollars in the next five years with a 3% adjustment for inflation). It was reported in the audit that almost 20,000 unwarranted exams (78%) were conducted without a pre-exam review that serves as an internal control justifying whether the exam is needed to verify the existence or severity of a disability.
Of these almost 20,000 exams that bypassed internal controls, almost 15,000 saw no changes to their ratings after the exam and only 4,000 saw reductions in their rating levels. In budget language, only 2% of the $100 million spent was warranted in showing a reduction of symptoms and actually saved the VA any money.
Of the 4000 exams that resulted in a reduction of benefits for a veteran, many of those get appealed and are re-awarded back to the reduction date when the veteran or their representative is able to prove the veteran’s symptoms have not gotten better.
C&P exams can often result in a reduction of benefits because of many factors, thus resulting in less VA compensation for the veteran. The main reason is the exam is not done thoroughly. If the VA examiner is not provided the full picture, including private records if the veteran is seeing an outside health care provider, the examiner may not have all the information he or she needs to make a complete assessment. Because of the stigma attached to C&P exams, former military service members are often reluctant to provide complete answers and sometimes even exaggerate answers because the veteran feels that they will be dismissed or not taken seriously. Unfortunately, this could harm their VA disability claim or disability rating, resulting in fewer benefits than they deserve.
Can Veterans Prevent Unnecessary C&P Examinations?
Preventing unnecessary C&P exams can help some individuals protect their veterans’ disability compensation. There are some things a veteran can do to prevent unneeded exams that not only waste money but also put their benefits at risk, often times erroneously.
- If you get a notice of a review C&P exam being scheduled, ask your representative if they can find out why the C&P review is required. If you have representation through a VSO at your VA regional office or an experienced VA attorney, they will be able to contact the VA and determine why the C&P is being ordered and, if necessary, gather evidence you may need to ensure that their rating is not reduced (unless it is truly warranted).
- Make sure treatment is consistent for the level of severity of the service-connected condition. For example, if you have a 70% rating for a mental health condition and are not seeing anyone for medication management or therapy, the VA is going to question if you are really disabled at that high of level. You can reduce the likelihood of this by attending treatment, even if you don’t participate, and having it noted in the records why you are refusing treatment, and making sure your symptoms are being recorded on a regular basis.
- Provide the VA with private treatment records when necessary. If you are seeing a private medical provider, the VA is not automatically going to request those records unless it is through Veteran’s Choice. However, your doctor’s medical opinions are an important part of your VA file. You can request that the private medical provider share your medical records with the VA, so the VA has a complete understanding of your condition and are is less likely to request an unnecessary C&P exam.
- Ensure the VA has records of any emergency issues that arise related to your service connected conditions. For example, if you are on vacation or out of the area and present at an emergency room, make sure to ask the VA to obtain those records for your claim file so they are aware of the condition and have complete records.
Working with the VA as much as possible to ensure that your records contain the information needed to continue to support your rating level is the best way for a veteran to reduce their chance of having a review C&P called as well as having their benefits reduced without warrant. This saves thousands of dollars per veteran and helps veterans retain their benefits at their current levels rather than risking reductions than having to fight to have their benefits reinstated. And…..the more money saved, the more veterans can be served.
You can learn more about C&P exams at VA.gov and other Veterans Benefits Administration materials.
