Will VA Doctors Write Nexus Letters? – Video

CCK Law: Our Vital Role in Veterans Law

Video Transcription

Emma Peterson: Good afternoon and welcome to another edition of CCK Live. My name is Emma Peterson and today I’m joined by Amy Odom and Brandon Paiva, and we’re going to be talking to you about “Will VA Doctors Write Nexus Letters?” This should be an interesting discussion.

So, generally speaking, a nexus letter is a document prepared for a veteran by a medical professional that connects an in-service injury, event, what have you, to the current condition the veteran is claiming service connection for.

Nexus letters can be submitted with a veteran’s initial claim, during claim development, or during the appeals process. So, it’s really part of the three steps of service connection that we’ve talked to all of our viewers about in past Facebook live videos, in our blog posts: an in-service incident or event, a current disability, and you need the Nexus and usually, you need some medical evidence to get you there.

So, Brandon, can you tell us a little more about why it’s important and go into some detail.

Brandon Paiva: You know, for a disability claim for direct service connection or for that to be successful, you need to meet or show the three main elements. Basically, these three main elements need to be present in order for VA to concede that your condition is due to service; therefore, service-connected.

The first element is you need a current medically diagnosed condition. The second element you need to meet is you need at least some sort of evidence to show an in-service event, injury, or illness, and last but not least, which is what this focus of the CCK live is about, is you need a medical nexus that actually links the currently diagnosed condition to the in-service event, injury, or illness.

Providing a medical nexus is often the most difficult part of this process, as it is going to tie the veteran’s claim for service connection together. Nexus letters can also be helpful following any sort of negative C&P exams, in which VA examiners can conclude that or will conclude that there is no evidence between a veteran’s claimed condition and their military service. Sometimes, getting a medical nexus opinion like this can sort of combat that and really help sort of substantiate a veteran’s claim for service connection.

Amy Odom: You will probably be surprised to know that your treating VA doctor, if you get your health care from the VA, is most likely not going to write you a nexus letter. The Veterans Administration is made up of two parts: there’s the Veterans Health Administration, that’s who employs the doctors that give you your health care, and there’s the Veterans Benefits Administration, and that’s where you go about your benefits claims.

The Veterans Benefits Administration has their own doctors and nurse practitioners and other medical professionals who conduct examinations and write nexus letters for benefits purposes. VA health care doctors have actually been discouraged from writing opinion letters for veterans in their benefits claims, though they’re technically permitted to, but because they’re discouraged from doing it, it’s really unlikely that you’re going to get one from your treating doctor.  They can, however, help veterans complete forms, including disability benefits questionnaires, which are forms that VA provides for the purposes of ascertaining the current severity of the disability. But those disability benefits questionnaires do not have a space asking for medical nexus information.

You know, in some respects, that might be a good thing that VA doctors don’t do this because, in order to establish entitlement to benefits, the VA Benefits Administration is going to look for very specific clear language. They want a specific and clear rationale and they’re going to look for magic words like “at least as likely as not“. In my experience when I’ve seen VA health care doctors write nexus opinions, they’re usually lacking these magic words and the rationale and don’t actually do the veteran any favors.

Emma: What can a veteran do? Can they go to a non-VA doctor to get a nexus letter if they need one?

Amy: Yes, they can. VA is permitted to review nexus opinions from even private doctors and, in fact, they must because they’re required to review all of the evidence that a veteran submits. But just like every medical opinion that is worth its weight, it has to have this clear and specific rationale and the magic words “at least as likely as not”. And if it doesn’t contain those words, the VA Benefits Administration is likely to reject it.

And also, another thing to keep in mind is that the VA benefits decision-makers often will favor their own medical opinions that they get from the Veterans Benefits Administration, doctors, or contracted doctors over a private nexus opinion.

Emma: Now Amy mentioned that, you know, VA is going to be looking for some magic language and a clear and concise report, so we have compiled a list of about 6 or 7, you know, quick tips that can help you get a good nexus letter from whatever doctor or expert that you choose to work with.

So, first and foremost, if it’s a medical nexus, you’re trying to prove that, you know, a medical disability happened in service, you want the report to be written by a licensed professional in that appropriate field. So what you don’t want to do is maybe go to your neurologist for an opinion about a skin condition, unless it happens to overlap. But you really want to try to target, you know, what’s the issue and go to the appropriate doctor licensed in that field.

And then, you want to also make sure that that medical professional and, I said the doctor—it doesn’t have to be a doctor. It could be a nurse, could be a PA, a licensed clinical social worker. I mean, there are a lot of, a wide variety of people you can work with, but whoever that person is, you want to make sure that they’re taking a look at your relevant service records. So, if you’re trying to establish service connection and you need that link to service, you want to make sure they’re looking at your service personnel records if that’s applicable, and your service medical records, and also any explanation that you might have to help that medical professional understand what happened to you in service.

You’re going to want to also make sure that they’re looking at your relevant medical history. So if you’ve been treating with VA for 10 years and it’s the first time you’re seeing someone, you know, outside of VA, go to the AMC and make sure you request all of your medical records and a copy, you’re entitled to that, and give it to that medical professional to review. They’re going to want to see what’s happened to you in between service and, you know, the current date. Have you always been treated or have you not treated and maybe explain why.

And then, you’re going to want to make sure that if they’re able to provide a positive opinion for you, that they use the standard of proof required for VA, which is “at least as likely as not”. And that can be tricky, I think, for medical professionals who don’t typically work in the VA world. That standard is very favorable. It’s a 50/50 standard. You just have to get to equipoise to get service connection.

So, make sure that your doctor or medical professional is not using the medical malpractice standard of beyond a reasonable doubt, or whether it’s the standard of care, or something that’s way higher. You need to explain to them it’s just as least as likely as not. If they use that language, that will certainly make the report stronger.

And then they’re going to need to provide some rationale. It’s not sufficient for them to say, “I’m a medical doctor, I’ve reviewed this, in my opinion, it’s as likely as not”. The reviewing VA personnel at the Regional Office or the Board of Veterans’ Appeals are going to want to see that the medical doctor or professional show their work.

So, just like in math class, back in third grade, you’re doing the times tables, you can’t just hop, skip, and jump. You’ve got to show the teacher that you know how to do it, carry the one, and all that stuff. So, make sure that your doctor you’re working with provides an explanation as to why they found that favorable opinion. And then, they want to be brief. It doesn’t have to go on and on, pages and pages are sometimes not helpful. Be brief, factual, and it should be evidence-based.

Now sometimes whoever you work with might come back with an unfavorable opinion, and they’re going to say it’s less likely than not. You don’t need to submit that. Just because you’ve gone out and gotten this opinion does not mean you have to submit to the VA. It does mean you should take a look and see what they’re talking about and see if you want to talk with someone else before going forward with your claim and certainly talk with a veterans service officer or an accredited rep or an attorney or whoever you’re working with on these claims.

But again, I think that the key takeaways are: licensed professional, service medical and personal records have been reviewed, medical history has been reviewed, using that “at least as likely as not” language, using a supporting rationale, and keep it brief and factual.

The other thing you’re going to want to ask this medical professional to include with their report is a copy of their CV or an explanation of who they are and what their background is so VA knows that they are who they say they are and they really are an expert in the field, and that will only help to strengthen that report.

You know, if you include all these things and all this information and points are in this medical report, all things being equal, there really should be no difference between a private medical opinion and a VA one. As Amy mentioned, VA-RO employees and sometimes the Board often prefer a VA examination over a private medical opinion, but they’re going to need to explain why. And so, if you go ahead and do some leg work upfront and include all of these points in your nexus letter, that can only help you.

Brandon: A lot of times, you know, in order to find a non-VA doctor to write a nexus letter, veterans may have to go through a thorough search process. The veteran should start by searching online for competent and qualified doctors who have experience in writing nexus letters. The key part there is to find somebody who is competent and qualified to write that opinion.

Veterans can search specific doctors who they’re already aware of, or they can start by searching a little more generally for a specialty doctor for X condition. Also, if you’re in doubt as well, you may want to reach out to the doctor or their office as opposed to a company. You know, it’s always better to kind of reach out to the doctor or that specific doctor’s office directly to hopefully kind of point you in the right direction to see if that’s something that they can assist with.

In some cases, the location of the doctor will matter, as oftentimes the veterans may have to attend an in-person examination in order for the doctor who’s writing that medical nexus opinion to really take everything into account. Once the veterans have found a few options online, they should reach out and research each doctor and obtain their background information. For example, veterans may want to request to review one of the doctors’ previous VA nexus letters to ensure that they include all the necessary details and information required for favorable finding. You’ll also want to check reviews from maybe potential previous clients or veterans who have worked with the doctor in the past as well in obtaining their nexus letters for their cases. If the previous veterans found that doctor’s nexus letter useful, that may give the veteran confidence to move forward with the process.

So, the big kind of take-home here is don’t be afraid to search our online but make sure that you have some sort of vetting process, make sure you’re sort of, you know, so to speak, doing your homework and making sure that this individual is the right fit. You want to make sure that this individual is credible, qualified, and competent and, you know, in this day and age with the 21st century, there’s a number of views you can potentially find online to try to get these individuals to write that medical opinion for you.

Emma: How much is this gonna cost? You know, I think people hear the word expert and they get very concerned. Is this going to be thousands upon thousands of dollars? What can folks expect?

Amy: Well, it likely will cost something around $1,500. That was the average in 2020, which can be a lot of money, and it may cost even more depending on the provider. So that’s why it’s really important to ask about costs upfront. Once you’ve selected and researched a particular doctor to look at your case, make sure you ask about costs upfront because they can vary a lot and it can help you to avoid scams because there are still bad actors in this space just like everywhere. That’s why you have to be really, really careful about who you pick, and asking questions and doing your research.

There are some doctors and companies that will offer nexus letters for free upfront, but then charge a certain percentage or a price if you get an award. But again, be really careful, there are a lot of bad actors. Well, I shouldn’t say a lot, but there are some bad actors in this area and you don’t want to be a victim of their practices.

Emma: I think the takeaway is to ask questions, right? Get it all in writing upfront and know what you’re signing up for.

Amy: If you are able to find a good doctor who’s willing to give you a solid nexus opinion, that can really make or break your case. So it is worth the effort of putting the research in to find somebody to figure out whether you can afford the costs and get that evidence in for consideration.

Brandon: You know, when you’re finding this doctor to complete this medical nexus for you, you can sort of treat it like an interview as well. Make sure that you understand that the individual is competent or, you know, ask them about their credentials, ask them about any sort of previous experience or any prior knowledge of them completing nexus letters for the VA. Because as we know and as Amy had stated, sometimes getting these medical nexus opinions are really pivotable and can oftentimes really assist in getting VA to concede service connection for your condition.

So, once you find a doctor, don’t be afraid to reach out and ask them as many questions as you have to make sure that they’re going to give you a well-reasoned, sort of a well-rounded kind of medical nexus opinion. And again, oftentimes, they will charge for this. So, you want to make sure that your money is going towards something that is going to, in the end, help your condition.

Emma: If people can’t afford it and again, these can be expensive, don’t despair. You can still get a service connection. So, this is for the cases where people think that they need or they’re accredited rep or VSO or attorney has suggested they get this evidence to really cross that finish line, but VA still has, under certain circumstances, a duty to assist and get an examination for you, and there are certainly are favorable VA examinations that come back. We see them all the time.

So, don’t despair if you’re hearing us talk about expense and things like that and I can’t do that. Still go to that VA exam and you’re very level best to explain to the VA examiner what happened to you in service and oftentimes that could be enough. But in cases where it’s not, a nexus letter is going to be necessary to ultimately get a service connection.

So, we want to thank you for joining us for our broadcast. And if you like what we talked about today, please be sure to subscribe to our YouTube channel to get notifications when we put up new videos. Any questions or comments? Please feel free to leave them in the comment section and we’ll get back to you just as soon as we can.

Once again, I’m Emma Peterson with Amy Odom and Brandon Paiva. Thanks so much for joining us.