43% of Recent Knee and Hip Surgery Claims Not Processed Correctly

For the first time since 1945, VA is performing a comprehensive review of its disability rating schedule. VA’s stated goal for the review is to better align ratings with advances in healthcare. The first revisions began to appear in August 2017.

Veterans Benefits Administration (VBA) started implementing changes to the musculoskeletal system rating schedule on February 7, 2021. One significant revision reduced the benefits for convalescence after hip and knee replacements from 12 months at a total disability rating of 100 percent to four months at 100 percent. The recovery period begins after a one-month total disability rating following hospital discharge, resulting in a total of five months for recovery.

Veterans with service-connected hip and knee procedures are also eligible for other benefits.

• Regulations require VA to consider special monthly compensation (SMC), which is additional compensation for unique needs. Veterans can receive SMC if they have a single service-connected disability rated as 100 percent disabling and an additional service-connected disability or disabilities independently rated at 60 percent or higher.
• If surgery for a service-connected knee replacement leaves a scar, then the veteran is not required to file a specific claim for VBA to consider service connection for the scar.
• VBA must also assign a percentage of disability following recovery, based on medical evidence and on the level of severity of the veteran’s procedure.

VA’s Office of Inspector General (OIG) recently conducted an evaluation of VBA’s implementation of changes to the rating schedule and the processing of claims around service-connected hip and knee surgeries.

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OIG Evaluates VBA’s Hip and Knee Surgery Claim Processing

The OIG examined 3,200 claims filed since VA revised the related schedule. They found that VBA did not accurately process approximately 1,400 of them (43 percent). A number of claims had multiple errors. Among the errors found by OIG:

• A third of the claims did not award the correct number of months for recovery. The periods of convalescence were both longer and shorter than the new guidelines.
• Almost a fifth of VBA’s decisions did not properly consider entitlement to SMC.
• Nearly 38 percent of all claims had at least one improper payment, either an underpayment or overpayment.

What VBA Did Wrong

First, the OIG concluded that VBA’s lack of a formal plan to conduct reviews led to a significant amount of inaccurate claims decisions escaping notice.

Second, while VBA did provide training on the changes to the rating schedule, gaps in the training led to almost 75 percent of staff needing to be retrained.

What the OIG Recommended

“The findings in this report are meant to improve the accuracy of compensation paid to eligible veterans who experience hip and knee replacements and resurfacing,” the OIG stated in their report. “The identified deficiencies may also be instructive for VBA when deploying future body system changes to the rating schedule.”

The OIG made several recommendations to VBA, including:

• Review all claims for hip and knee replacements and resurfacing filed between February 7, 2021, and August 31, 2022. Wherever necessary, take appropriate actions to correct veterans’ benefits awards.
• Implement a plan to assist staff in calculating the duration of convalescence.
• Develop a process to monitor claims and identify inaccuracies.
• Improve training on the rating schedule changes.

VBA accepted these recommendations and began planning for implementation.

What We Think This Means for Veterans

This is far from the first time in the last 25 years that we at Chisholm Chisholm & Kilpatrick have seen VA applying laws and regulations inconsistently. It is unfortunate when this creates uncertainty for veterans, and the impact of the upcoming review remains to be seen. But here are our initial observations:

• If you were awarded benefits for knee or hip surgery between February 7, 2021, and August 31, 2022, VA might reexamine your claim. VBA has been both under- and overpaying veterans, so a review might be good or bad news for you.
• The most dramatic change might come if VBA had given you the original, 12-month period for recovery. The new rules reduce that period by eight months.
• Other changes could be to SMC benefits, scar evaluation, or post-convalescence VA rating determination.

When To Ask for Help

If you feel that you received an incorrect decision regarding your knee or hip procedure claim, please reach out to CCK. As the largest veterans law firm in the US, we have over 300 years of combined experience appealing incorrect awards, forcing VA to clarify and apply rules, and obtaining compensation for veterans. Contact us for a free case evaluation to determine if we can assist you.