1st Quarter 2013 Veterans Affairs Canada Intelligence Report
Assessment by Former Head of Military Intelligence
27 May 2013, Monday – Calgary, Canada – 1st Quarter 2013 Veteran Affairs Canada (VAC) Intelligence Report is derived from hundreds of pages of documents and thousands of minutes of communication with personnel at all levels and sub departments of VAC over the first quarter of 2013. The intent of the report is to advise veterans of the challenges faced when dealing with VAC. 20 recommendations are proved to help veterans and assist VAC in transitioning towards a professional and effective organization.
During the first 4 months of 2013 both internal and external issues were identified from 12,600 minutes of communication with more than 40 personnel and a review of 82 documents containing 570 pages, 579 emails and 163 conversations with VAC.
Based on the largest benefit to veterans, VAC's challenges are:
1. Improving Internal Communication.
2. Improper use and interpretation of the Privacy Act.
3. Improving External Communication.
4. Lack common sense in assessing veterans needs.
Improving Internal Communication.
1. Special Authorization (SA) Units. The greatest danger that all veterans face are these units which, according to VAC personnel are covert units, highly sheltered and inaccessible to external personnel who activate when certain medications are requested by pharmacists for approval. According to VAC personnel these units exist to reduce the medication costs by challenging physicians treatment plans to ensure they have exhausted all cheaper drug therapies. These units act as front line health care providers in practice, but are strictly cost control units which take 4 – 6 business days to evaluate a veterans requirements for specific medications and verify they are for service related injuries. In the case of life-sustaining medications, if the veteran runs out before a favourable decision is made, their life literally is placed in harms way. According to SA Unit personnel, they have no access to review and communicate with nurses who complete initial assessments which record all current medications used by veterans. In comparison to a minefield, VAC personnel wait until a prescription triggers the unit, sending a barrage of shrapnel in the form of panic and anxiety into the most vulnerable of disabled veterans which require life-sustaining medications. Some veterans are left in the minefield for 4 – 6 business days before the SA Units decide if they will be evacuated to a safe zone where their medication is approved. A second danger of this unit is exposed when a veterans triggers the unit on weekends or outside their standard business hours, a 40 hours work week, 8 hours daily, Monday through to Friday, in the maritime time zone. Contrary to information contained on VAC's website (1) which states there are emergency protocols in place for “critical medications”, veterans have been denied life-sustaining medication on numerous occasions and told by experienced case managers and in one case, an acting area director, there was no emergency protocol and advised the veteran he would have to wait the 4 – 6 business days until a decision was made.
1. Assessment and Recommendation (01): In assessing the unit usefulness based on information from VAC personnel and other veterans, a simple work around would require, at a minimum, that the nurse or case manager, immediately following the initial assessment take the 15 seconds per medication and input the DIN or drug name into the SA Unit medication database, which is available to all VAC staff and instantly identify SA Unit drugs. However, based on veterans who have triggered these units with life-sustaining medications, they are redundant and serve to discriminate against veterans based on the severity of their disability. In addition, VAC personnel could not verify if they were infringing upon provincial jurisdictions by acting as front line medical providers, but without the 24x7 support that provincial health authorities provide.
2. Sharing information among VAC personnel. A number of tests were undertaken to identify the effectiveness of VAC personnel to share information across sub departments and up/down the chain of command.
1. SITUATION #1. Disgruntled Suppliers. Information was sent to a case managers and an area director identifying a major medical supplier which was refusing to direct bill VAC on behalf of veterans due to extreme payment delays resulting in veterans paying for medical supplies out of pocket and submitting receipts to VAC for reimbursement which were later denied, exposing another internal communication issue. Several weeks later, the same VAC personnel were contacted and asked if an investigation had been undertaken and if the issue was resolved with the supplier. The personnel would not verify if this had occurred. Following this response the minister's office and deputy minister's office was contacted and personnel denied knowledge of such situations and this specific situation. Months later the minister and deputy ministers office refuse to verify if an investigation was conducted and if the situation with the medical supplier was resolved.
1. Assessment (02): Assessing the Area Manager in this situation, following the original communication there was no information flowing up or down the chain of command. Recommendation (02): At a minimum veterans who were unable to obtain medical supplies should be informed if or when the situation was resolved. It is more beneficial to the client, veterans, to be informed as they take the brunt of the suppliers frustrations both verbally and financially.
2. SITUATION #2. Original Receipts. Copies of receipts from one veteran were sent to a case manager who forwarded them to the Client Reimbursement Unit. In some instances it took two months to deny reimbursement by VAC based on the requirement for original receipts. According to VAC personnel the case manager who forwarded the receipts is considered experienced. VAC has not explained or responded to this issue.
1. Assessment (03): Assessing the case manager in this situation, there was no communication between the Client Reimbursement Unit and the case manager advising of this issue. Recommendation (03): VAC personnel require training to advised veterans that original receipts are required and thus prevent an estimated 4 month delay in reimbursement.
Improper use and interpretation of the Privacy Act.
Prior to explaining the improper use and interpretation of the Privacy Act by VAC personnel, #1 to #4 briefly interpret the Privacy Act and other Acts in accordance with the Privacy Commissioner of Canada and the Treasury Board Secretariat of Canada.
1. There are two fundamental objectives of the Privacy Act:
1. Protect the privacy of individuals personal information; and
2. Provide individuals with a right to access their personal information.
2. Information is not to be collected unless relevant to programs.
1. S.4. states "No personal information shall be collected by a government institution UNLESS IT RELATES DIRECTLY to an operating program or activity of the institution." Therefore the information must be relevant to its use. The policy requires that institutions have administrative controls in place to ensure that they do not collect more personal information than is necessary for the related programs or activities.
3. Direct collection where information is to be used for an administrative purpose.
1. S.5.1 states "A government institution shall, wherever possible, collect personal information that is intended to be used for an administrative purpose DIRECTLY FROM THE INDIVIDUAL to who it relates". This is the priority of the Act. The Act requires that, with very limited exceptions, institutions collect personal information that is intended to be used for an administrative purpose directly from the individual to whom it relates wherever possible. The phrase "wherever possible" is expected to allow for collection of personal information from another source when the individual is unavailable or cannot be located within a reasonable time. It does not permit the indirect collection of personal information using Section 8(2) because it would be easier or less costly than direct collection.
4. Informing the individual of the purpose of Collection.
1. Section 5.2 states "A government institution SHALL INFORM any individual from whom the institution collects personal information about the individual OF THE PURPOSE FOR WHICH the information is being collected".
1. Example #1. VAC Application forms clearly state the purpose at the start and/or the end. “The personal information received by VAC ... (will be used) to decide if individuals may be eligible for additional benefits” and “Providing this information is voluntary, however failure to complete any part of this form may result in delays, or an adverse decision for the Member/Veteran.”
2. Example #1. VAC Medical Questionnaires for Physicians state "This medical questionnaire is used for the evaluation of conditions with multisystems or global body effects" and is "for the purpose of determining disability entitlement and/or assessment".
This section requires that a government department inform the individual of their right to know and understand the reason their information is being collected and how it will be used. When indirect collections occur, for example under S.8(2), the government is still required to inform the individual of their right to know and understand the reason for the collection giving an individual the opportunity to respond. However, VAC personnel claim that they have the authority to disregard information at their own discretion contrary to the stated purpose of its collection.
2. In requesting specific legislation from VAC to access, collect and use personal information without the permission of veterans, various acts were cited:
1. Section 4 of the Privacy Act authorizes VAC to collect personal information. This section does not provide “Our (VAC personnel) the authority to collect, use and share personal information” without the consent of the veteran.
2. Section 5 of the Privacy Act “states that the Department (VAC) does not need to collect personal information from you if we already have the legislated authority to collect it ourselves from another source”. This section clearly states (VAC) must collect personal information from the individual and makes no mention of legislated authority.
3. Section 8.2.b of the Privacy Act “further supports government's authority to disclose your personal information without your consent” relates to an exception to the “Disclosure of personal information”, which, according to the Treasury Board of Canada Secretariat (2) “Privacy and Data Protection Guidelines”, states “this exception is designed to avoid placing an unnecessary response burden on individuals” and does not automatically allow VAC to obtain information, except where an individual provides written authorization. Again, veterans who have not given written authorization for VAC to collect information on their behalf or veterans who have issued Withdrawn Consent Orders are accepting this “burden”. VAC cannot usurp the authority of the veterans in the above situations.
4. Section 81 of the Pension Act. This section which makes no mention of access to personal information.
5. Section 109 of the Pension Act. This section does not apply to veterans who have not authorized VAC to collect information on their behalf or where a veteran has issued a Withdrawn Consent Order.
Canadian Forces Members and Veterans Re-Establishment and Compensation Act
1. Section 81 and 82 of the New Veterans Charter (aka Canadian Forces Members and Veterans Re-Establishment and Compensation Act). These sections allow the Minister to disclose personal information or collect an individuals Social Insurance Number, but does not allow department personnel to access personal information. If the Minister obtains the information directly, upon written permission from the Minister, this information can be disclosed to VAC personnel. Section 81.b., contrary to VAC personnel statements, does not allow “the Minister to authorize (delegate) employees of the Department to carry out legislated functions on the Minister's behalf.”
Department of Veterans Affairs Act.
2. Sections 6.6 and 6.7 of the Department of Veterans Affairs Act. Section 6.6 states “Information that shall be made available to the Minister” and makes no mention of delegating authority to VAC personnel. Section 6.7 states “Information that Minister may disclose” information to VAC personnel, and Section 6.7.b. makes no mention of delegating the Ministers authority to VAC personnel “in order to confirm, or verify your service and health records”.
3. VAC personnel also stated Section 6.6 of the Department of Veterans Affairs Act confers that “we (VAC personnel) had a duty to verify the information you gave us”. This section makes no mention of a duty to verify the information and, as stated above, clearly relates to the Minister and not VAC personnel.
5. A number of cases were reviewed where Withdrawn Consent Orders were issued by a veteran:
A Withdrawn Consent Order removes all previous written consent to VAC. It forces the department to follow the Privacy Act and request information directly from the veteran who can then action the request and send the appropriate information back to VAC. This also eliminates indirect collection and use of information without the veterans knowledge.
1. VAC personnel disregarded the veterans right to obtain the information and went directly to the source. An Adjudicator contacted another federal department, without the veterans authority, to verify the authenticity of a document provided by the veteran which contained personal information.
2. Contract personnel for VAC, without authorization, provided personal information to VAC. The veteran agreed to provide information to the contracted person for a review and recommendation of Home Care, but would not authorize the information being sent to VAC until a review was discussed between the contractor and the veteran. In this case, the requested information was obtained, the contracted person did not review the recommendation with the veteran and without authorization provided the information to VAC.
3. VAC case manager disregarded limited consent authorization. The veteran agreed to allow a case manager to contact a physiotherapist for the purpose of setting up a billing procedure. The case manager disregarded the authorization and requested assessments and discussed personal treatment information from the physiotherapy company. The veteran's health was negatively affected due to a shortened treatment period agreed upon between VAC and the Physiotherapy company. In addition, the veterans relationship with the physiotherapist was negatively impacted when he discovered he was not consulted by the physiotherapist who indirectly provided personal information to VAC.
6. A number of cases were reviewed where a veteran has requested copies of their personal information from VAC.
1. VAC file tagged with a “pop-up” which denies the veteran access to VAC personnel and contains a threat. According to the veteran and verified with a VAC ombudsman his file contained the following statement “case managed veteran is to be transferred to his case manager in the (local) district office for ALL INQUIRIES relating to his case plan and/or if the client is refusing to identify the nature of his call please advise him that a message is being sent to his case manager”. The veteran requested that this message be removed from his personal file in accordance with Section 12(1)(a) and 12(1)(b), Right of Access including Section 3, Personal Information, and to date VAC has refused the request. In addition, the veteran feels the threat to send a message to his case manager has resulted in damage to his health by preventing him from discussing specific issues with covert VAC units.
2. Operators advise veteran they cannot send messages to covert units. A veteran obtained a decision from an Adjudicator and requested a brief 2 minute conversation to clarify one detail of their personal medical information used. The veteran stated he was not unhappy with the decision. To date the request has been refused.
3. VAC ATIP office is more than 5 months behind a request for copies of a veterans personal information. A veteran requested copies of log files, correspondence and his personal files and has received two extensions. The last extension expired on 30 April 2013 and VAC has refused to provide the requested information. In an effort to expedite the process, the veteran sent letters directly to 30 VAC personnel who have been involved in his file requesting they forward all personal information to the VAC ATIP office. To date, only the Bureau of Pension Advocates advised the veteran they would comply with the request however the VAC ATIP office has not sent any of this information to the veteran.
4. Veteran asks to be CC'd on all correspondence within VAC regarding his personal information. This request was also sent to the VAC ATIP office. To date the request has been refused.
7. A number of cases were reviewed where a veteran has requested VAC personnel contact information and was denied.
1. Veteran denied request for direct phone number of his case manager. In accordance with the Privacy Act, Section 3(j)(i) and 3(j)(ii), “personal information”, a veteran requested the direct number of his case manager. In reviewing the the phone directory for VAC personnel, it was discovered this case manager was the only person within VAC that listed his direct phone number as 1-888-522-2122 which advises the veteran the number is not available in their calling area. In addition, the case manager stated to a veteran on two occasions that he refused to provide his direct number.
2. VAC operators and case managers claim they are unable to provide the direct number of covert units. A veteran requested to speak with the Special Authorization (SA) Unit and was advised no direct number existed. The veteran contacted a pharmacy and was provided the number for the SA Unit.
3. A veteran requested to speak with a specific regional director. A veteran called the main VAC number and was advised by the Operator they did not have a direct number for the regional director. The veteran called a second time, speaking to a different Operator who connected the veteran with the regional director through a cellular phone number. The call was disrupted and disconnected due to signal loss. The veteran called the main VAC number a third time, speaking to a different Operator, explaining he was disconnected from his call. The Operator then stated they had no direct number for the regional director.
8. A number of cases were reviewed where information was requested by VAC personnel and used for a purpose other than stated.
1. VAC requests and reimburses physicians for medical information which supports Disability Applications and VAC then refuses to use it. On numerous occasions it was documented that VAC personnel disregarded information which supported the applications. In accordance with Section 5.2 a government institution CAN NOT collect information for the stated purpose of evaluating an application and not use it. Since “non-use” was not the stated purpose of collecting the information, Section 5.2 is breached. Although this problem was identified in a recent Ombudsman report as “cherry picking documents”, it is not consistent with the stated purpose of collection.
2. VAC requests and reimburses physicians for medical information which supports Rehabilitation Applications and VAC then refuses to use it. Numerous cases were discovered. The information provided above in #1 also applies to this situation.
3. VAC personnel verbally approve treatment benefits pending specific information provided by the veteran, then denied the benefits. Following the investigation into one veterans case for one treatment benefit, it was uncovered that VAC personnel verbally requested and approved the benefit pending specific information being provided. The veteran provided the requested information and was then denied the benefit and told it was not sufficient . The VAC personnel then verbally approved the benefit again, pending different information being requested. Over a 4 month period the veteran submitted to the increasingly challenging requests 5 times. The veteran compared the VAC process for approving benefits to hitting a moving target from 300 yards away with a hand gun and, after the 5th request, felt they it impossible to accomplish. The veteran was then diagnosed with General Anxiety Disorder, attributing the majority of the diagnosis to the the challenges of dealing with VAC.
Assessment (04): In the cases reviewed, VAC personnel are untrained in the Privacy Act and frequently quote sections of the act which are not relevant or claim the Act does not pertain to them, quoting other acts. It is clear VAC personnel from the lowest to the highest level including the Ministers department have a complete disregard for the Act and have a sense of entitlement to request, collect, access and use any information from any source they choose, regardless of its accuracy or relevance to a decision. Recommendation (04): All VAC employees undergo extensive training as per the Treasury Board of Canada Secretariat Privacy and Data Protection Guidelines.
Improving External Communication.
1. A number of tests were undertaken to identify the effectiveness of VAC personnel to share information between veterans and VAC.
1. SITUATION #1. Benefits Unused. Requests were sent to multiple VAC personnel including a VAC case manager, and both the Ministers and Deputy Ministers office to change a veterans registered massage therapist, reduce the frequency, increase the session time, and change the provider to mobile therapy. VAC was advised of the significant health benefit to the veteran in approving a mobile therapist and a net financial gain to VAC in reduced travel expenses and increasing the session time. Despite numerous requests, no response was provided by VAC. A month later, after the request, it was learned from an anonymous source that VAC had altered the therapist and approved 10 sessions which expired within a two week period. The department was advised the veteran was not informed of the approval and thus was not able to use the benefit. The veteran was then advised a Request for Extension of Treatment Program Form would be required from the new therapist to continue authorization of treatment benefits. The veteran advised he has a physicians prescription but VAC continues to require the extension form from the therapist. The therapist advised the veteran, based recent and previous experience with VAC, that he will have to directly pay for the cost of treatment and any assessments or forms. The veteran subsequently paid for treatments and submitted receipts to the Client Reimbursement Unit which were denied. VAC has refused to respond to inquiries regarding this issue.
1. Assessment (05): In assessing VAC in this situation, the department did initially response to the request, but in failing to inform the veteran, denied the health benefits which were approved. Although the veteran has a physicians prescription it is unclear how VAC would benefit from a therapist report with little or no experience treating the client. The lack of communication is the central problem as this situation demonstrates but also exposes additional problems with forcing veterans to pay for treatments out of their own pockets which are then refused for reimbursement and aggravates treatment providers to the point where they refuse to deal with VAC. Recommendation (05): Case managers should undergo training to inform clients of a time sensitive approvals which benefit the health of veterans. In addition, VAC should implement a procedure to require treatment providers a minimum number of treatments prior to requiring therapists to complete a request for extension form. .
2. SITUATION #2. Communication with Pension Officers, Adjudicators and VAC Physicians Prior to Benefit Decisions. A number of applications were reviewed over a one year period and those that were declined, were based on false, misleading or information which confused VAC personnel. The following process was derived from the documentation obtained through an Access to Information and Privacy request. It is important to distinguish between the procedure VAC claims to use versus real situations derived from actual documents.
The first person within VAC that reviews the information is the Pension Officer which further prepares the application and forwards to the Adjudicator, a registered nurse. In cases where medical information requires clarification, the adjudicator would then request a medical opinion from a VAC physician. Three cases demonstrate the lack of communication by VAC personnel:
1. CASE #1. Disability Application. A disability application was denied due to a VAC physician making false and misleading statements. In addition the VAC physician reinterpreted other physicians reports which were cited in the decision as the primary reason it was denied. In addition, another physicians statement, which supported the application, was not used. When asked why some physicians statements are not used a pension officer advised “VAC has chosen not to use this information”. This application took 6 months for a decision and included a “RedZoned request” to speed up the decision making process. The application was approved after another 5 months following a second internal review which included consultation with the veteran by the Adjudicator prior to a decision being made.
1. Assessment (06): In assessing this case, it is clear numerous physicians statements confused both the original Adjudicator and VAC physician. Recommendation (06): VAC physicians should contact other physicians to clarify the information in their statements. This prevent secondary reviews and allow veterans to access benefits months earlier.
2. CASE #2. Rehabilitation Application. A Rehabilitation application was denied due to an existing disability application under review. First, the veteran was advised by a case manager that his rehabilitation team did not have the authority to make a rehabilitation decision. A Client Service Agent then stated the case manager did have the authority to make a decision. Then the veteran was advised by a different VAC employee that the case manager, and not “his rehabilitation team” has the authority to make a decision on approving rehabilitation. Next, the veteran was advised by the case manager, his team could not make a decision on the application in case the disability application for the same injury was denied. The case manager advised the veteran that “if I approve your rehabilitation application, I cannot remove your benefits if your disability application is denied”. Finally, the case manager told the veteran that the injury was not caused by military service in the Canadian Forces. The veteran had provided military medical documents establishing he was on duty at the time of the injury, was ordered to perform the task which injured him, and documents verifying the task he was ordered to perform and the injury which resulted, however the case manager continued to claim the injury was not caused by military service. Two months later, following a letter from the CF which included the words “service related injury”, the application was approved.
1. Assessment (07). In assessing this case it is difficult to understand why the case manager provided 3 different explanations for denying the rehabilitation application and the contradictory information provided by another VAC employee. Recommendation (07): To resolve issues of “service related injuries” in a timely manner case managers should contact the CF and verify the injury was service related which, in this case, is how the veteran resolved the problem.
3. CASE #3. Medical malpractice and mismanagement. An disability application was made to VAC regarding the medical malpractice and mismanagement of the information by a VAC physician. A Neurologist for a veteran obtained a copy of the VAC Physicians Medical Report and upon reviewing the document the Neurologist provided a written response regarding the VAC physicians interpretation of his report which was used specifically to deny the veteran benefits. According to the Neurologist the words “This is incorrect” summarize multiple conclusions of the report which ultimately were cited as the reason the application was denied. Upon conducting an investigation into the background of the VAC Physician it was learned that he maintains only a general surgeon qualification, with no specialty in neurology. He has worked for VAC for 4 years, but was trained in disability medicine for the first 2 years and maintains that VAC's required only 3 qualifications for him to be entitled to make false statements regarding neurological diseases, re-interpret neurology reports and mislead the Adjudicator with his conclusions. To be qualified as a Medical Advisor he needs to hold a valid license to practice medicine in Canada, is a member is good standing of his local College of Physicians and Surgeons, and is a member of the provincial Medical Society. These standards have not been changed since 1997. Upon bringing this incident to the attention of the Deputy Ministers office, one of the senior personnel agreed this incident was serious and warranted an investigation. Upon following up with The Minister and Deputy Minister's office no response was provided and an investigation was not undertaken. Several months later, a check was completed to verify if the same doctor was released or continued to practice as a physician for VAC. The results of the the check confirmed he continues to work for VAC. The veteran is 100% disabled. Several months later the disability application was approved and according to the Bureau of Pension Advocates the Adjudicator made an extraordinary admission in writing that if the diagnosis was confirmed sooner, earlier treatment options may have been available.
4. Assessment (08). In assessing this case it is clear that the Adjudicator and VAC Physician did not understand the technical documents provided by one of the Neurologists. Without commenting on the Medical Act and Code of Ethics for both nurses and physicians, the single most important aspect of this case is the veterans health. Recommendation (08): To resolve this situation the Adjudicator and the VAC Physician should have contacted the neurologist for further clarification. Given the seriousness of the the veterans injury, his health and quality of life would have been significantly improved over the 12 month period that it took VAC to obtain a favourable decision.
3. SITUATION #3. Communication with Covert Units and personnel. To date a number of covert units have been identified within VAC which include Special Authorization Units, Medical Advisors, Adjudicators, 1st Level National Appeals Units, Centralized Processing Unit, to name a few. The most important aspect of these units are the impact on veterans by making benefit decisions without any communication with external parties. A few exceptions have been uncovered where an Adjudicator needed verification of a document originating form the CF and upon the insistence of a veteran, an Adjudicator discussed his case prior to a benefit decision, these units are closed to all external entities. In all other cases reviewed, these units rely 100% on documentation provided by the veteran or obtained by the Pension Officer or Case Manager. On multiple occasions, when applications were denied, it was found the covert units making the decisions chose not to use specific information, did not understand the medical information provided or misinterpreted reports.
1. Assessment (09): In assessing these cases, it is understood that a basis of information is required to establish both an injury and its relationship to service, however in failing to clarify information and then rejecting an application because a call was not made to a physician or veteran is a waste of VAC resources. When an appeal is then made the process again wastes additional resources. In the meantime, the veteran is denied benefits and their health is negatively affected. In comparison to the DND, VAC works as if it is an ultra secure special operation with the difference that information flows in and out of the DND. VAC has demonstrated that communication flows in but rarely out in a timely manner. Recommendation (09): To resolve this situation, veterans should be given the opportunity to discuss their case with these covert units prior to decisions being made. In the cases reviewed, when a veteran is aware that information requires clarification from themselves or their physicians the information was obtained and the applications were resolved without appeals being required. In the long run, this will save VAC considerable resources, improve relationships and trust with veterans.
4. SITUATION #4. Direct communication with VAC personnel. 4 minutes and 30 seconds is the average time spent on hold and screened by a VAC operator when calling the VAC 1-866 number to speak directly with specific personnel such as a Client Service Manager or Case Manager. All communications with veterans are routed through the front line toll free numbers. VAC personnel have advised that their are protocols in place to prevent all veterans from contacting VAC personnel within the organization. No direct numbers or email addresses are provided and all calls are screened. In investigating the purpose of not providing a veteran with his case managers direct phone number, a number of explanations were stated:
1. The first claim by a case manager was that VAC needs to verify the identity of each caller to prevent imposters from obtaining Protected information of a veteran. According to one veteran, case managers are similar to sales people and are there to service veterans needs. Large telecom companies use similar methods to screen customers but have found that using automated systems which delay contact and consume vast amounts of a client time, lead to increased frustration and resentment.
2. The second claim by an operator was that by screening veterans they are able to prepare the personnel, to whom they are seeking to speak with, advance notice of requests and reasons for their call. In testing this claim, a veteran called with a specific request which, by the time he was transferred his case manager was not aware of the veterans inquiry and the veteran had to explain his request a second time.
3. The third claim by a VAC employee was, in the event of emergency situations, a veterans case manager may not be available however an on-duty case manager is available 24x7 to address these situations. As mentioned above when a veteran was denied life-sustaining medication the case manager was unable to accommodate the request for an emergency supply and therefore VACs claim that the 1-866 number is designed for emergency situations is false.
4. The fourth claim by a case manager was that he was frequently in transit visiting clients. He claimed leaving messages on his office answering machine would not be retrieved until he was back in the office. He stated it could be days before he was back in the office and could retrieve messages, however by using the 1-866 number VAC operators are able to contact him immediately via other means which the operator would not explain.
A number of tests were then undertaken to test the ability to obtain direct contact with VAC personnel in a number of departments. With a few exceptions, the VAC operators were efficient 99% of the time preventing the disclosure of nearly all requests for direct numbers to VAC personnel to veterans. However, it was found that if the caller did not disclose they were a veteran, then access to requested personnel increased to a 50% success rate. One veteran also reported that due to the frequent requests and inquiries he was making, an average of 90 minutes each month was spent being screened by operators which was becoming a source of frustration. In comparison with provincial health authorities, for example Alberta Health Services (AHS), this level of security is not used. For email communication, AHS maintains a Trend Micro encrypted system for external personnel and patients. Also AHS encourages personnel to contact parties specific to the needs of the patient and provides phone numbers and other methods to contact relevant personnel. According to VAC personnel, the department maintains a secure login location where documents can be shared, however registering and using the system is not user friendly and older veterans with limited computer skills will find this system is more difficult to use that newer ones such as those used by AHS.
1. Assessment (10): VAC could not provide a consistent or relevant reason to deny direct contact with personnel specific to the veterans needs. As a veterans disability increases, so does the amount of time spent communicating with VAC. This leads to an increase in time required by both VAC and veterans, however the amount of frustration increases only for veterans due to the lengthy wait times. Recommendation (10): To resolve this situation, operators should forward calls immediately to the requested parties. Training should be provided to allow VAC case managers or client service agents to perform client screening which is a simple function an in some cases not required for general information requests. In response to the case manager who is traveling, one veteran suggested that the he investigate the use a service called “remote message retrieval” developed in the 1980s and designed to allow personnel to retrieve their voice mails from any phone with touch tone service. In addition, VAC personnel should provide their email address and obtain an encrypted messaging service similar to provincial health authorities which would allow veterans to discuss information in writing and allow documents to be shared. In a timely manner. The current system is archaic and difficult for some veterans to use.
Lack of common sense in assessing veterans needs.
1. Veteran advised a prescription is required for reimbursement of a $17 shower diverter. A veteran was advised by home care workers that the existing shower diverter to a hand wand was, at 7 feet, too high for home care workers to safely turn on. The veteran changed the diverter and submitted a claim for reimbursement citing safety concerns from provincial home care workers. The claim was denied and when the veteran contacted VAC, he was advised a prescription was required from his physician to approve and process the payment.
1. Assessment (11): VAC personnel are following outdated and unreasonable procedures. Recommendation (11): VAC implement a discretionary dollar limit for approvals below, for example $100 items, and accept veterans verbal evidence of the needs.
2. Veteran requests increases in VIP benefits and VAC personnel decide to reduce benefits. A veteran requested an increase in VIP benefits for Grounds Maintenance based on increased costs. Although not required, the veteran included a copy of the increased costs and advised 3 quotes had been obtained and the lowest quote was chosen. In response to the request VAC personnel not only denied the request but reduced the Ground Maintenance benefits, citing the Grant Determination Tool versus the veterans need.
1. Assessment (12): VAC personnel continuously claim if there a “need” then VAC will fulfill the need. In this case the need is clearly stated, however regardless of the request being denied, there is no logical reason why the benefit was reduced. Recommendation (12): When benefits are reduced, a supervisor, manager or area director should review and sign off on any reduction. This will reduce any errors or decisions based on personal opinions.
3. Veteran requests an additional VIP benefit and is advised it is now included in the existing benefit thus reducing total benefits. In accordance with Program of Choice 15, a veteran requested window cleaning, one of three housekeeping items. VAC personnel advise the veteran window cleaning was now included in the original VIP Benefit for Housekeeping thus reducing the total benefit.
1. Assessment (13): VAC personnel have intentionally interpreted the benefit grid to include the separate item in general housekeeping. Following this logic, you could interpret the cost for a physiotherapist report is included in physiotherapy treatments, which is clearly not in accordance with VAC's own procedures. Recommendation (13): VAC develop an investigation department for veterans to determine if employees are denying veterans benefits for personal reasons.
4. VAC case manager questions the service related injury, approved disability and rehabilitation benefits, refusing to grant benefits. A veteran is assigned a new case manager and provides a list of the diagnosis and symptoms approved by VAC. Provincial health authorities recognize the veteran requires a number of home care services. The case manager, who has no experience as a front line health professional, questions both the decisions of the VAC Adjudicator and the provincial health authorities and denies benefits, based on his personal opinion, negatively affecting the health of the veteran.
1. Assessment (14): The case manager clearly does not agree with the Adjudicator's decision and the provincial health authorities assessment of needs. Following an investigation into numerous case managers conduct, this was the first time a case manager with no formal medical training, refused to accept both internal and external health professionals decisions. Recommendation (14): Transfer employees who are intentionally impeding the benefits of veterans to roles which have no involvement with clients.
5. Special Authorization Unit refuse to pre-approve client medication lists and requests doctors call them for medication approval. In the coarse of investigating the covert SA units, one of their personnel was asked why they are not provided copies of nursing assessments with medication lists to pre-screen veterans for special medications and was advised “we are too busy”. They were then asked, once the approval was obtained, if they could call the veteran directly to advise them and was again advised “we are too busy”. The SA unit personnel explained that veterans are responsibility for finding out when their special medications are available. She stated veterans should continuously contact their pharmacist and requesting a prescription fill to find out when it is available. In addition, she advised the quickest method to obtain an approval was to have a doctor directly contact them using the same number as the pharmacists. It was pointed out to her that the number provided to pharmacists is not a direct number and were given the general VAC Operator's number to contact the SA unit. However, she was advised the Operators have stated to veterans on multiple occasions that the SA unit does not have a direct number, therefore a doctor calling VAC would not be able to contact the SA unit. Her response was that if a doctor called, they would be transferred through to the unit and that veterans are not allowed to call them directly and discus any information with them. When asked if they would pay for the doctors time spend waiting on hold and discussing the medication with the SA unit, on average taking a minimum of 10 minutes, the SA unit person stated they would not be reimbursed. When she was advised multiple physicians were contacted and asked if they would call VAC, they stated they were too busy and they would not waste their time on hold when they have other patients to assist.
1. Assessment (15): SA Units absolve themselves of all responsibility related to the harm that can occur when special medications are not approved immediately. They provide front line health care, but show no interest in helping the client, the veteran by their covert nature. Recommendation(15): At a minimum all veterans should be informed by SA units via a phone call or message immediately when their special medications have been submitted for approval and once the approval occurs. However, in evaluating the risks associated with these covert units versus the benefits, it is clear that delaying special medications can be life-threatening and thus the most beneficial decision would be to disband these units, eliminate or reduce the special medication process. All medications should be approved as per their physicians directions unless proven otherwise unrelated to a pensionable condition, similar to the judicial system “innocent until proven guilty”. Case manager can provide the veteran with a written request to forward to their physician to verify the medication is related to one of the conditions listed in the letter. This is the same process which occurs when an application is first made and a Questionnaire is sent to the veterans physician and they are reimbursed for completing the form.
6. VAC Operator's hang ups up on veteran. A veteran was attempting to contact a regional manager and the VAC Operator argued with the veteran regarding the purpose of his call. The veteran stated he did not wish to discuss the details with the operator and then the operator hung up. The veteran called back and talked to another operator asking why an operator would hang up on him. The operator stated if a caller was using explicit language and using fowl language at the operator their procedure is to terminate the call. The veteran explained the details of his last conversation and the operator stated that was not grounds for hanging up and apologized on behalf of the other operators behaviour.
1. Assessment (16): VAC Operators are under constant stress due to the aggressive screening techniques and extensive information gathering they conduct when answering veterans calls. In a number of instances they will send a message to the person who the veteran is seeking to contact but not provide the phone number for direct communication. It is also apparent that VAC Operators at times, are extremely busy managing calls, which creates stress caused on them by discussing and documenting the details of lengthly requests. Recommendation (16): At a minimum, VAC Operators should direct requests to the voice mail of individuals or sent short messages detailing the time, date, person and call back number which would reduce the stressful job of obtaining details from callers, which can take several minutes to an hour in complicated situations. The best solution is for VAC operators to comply with callers requests and forward the calls to the person and provide their direct number preventing future calls to VAC operators. This would allow for a significant reduction in the number of VAC operators required and ease both the frustration for the callers and operators.
7. Veteran obtains prescription from a physician regarding special regarding equipment and is denied. A veteran requires a special piece of equipment costing less than $1,000 which will significantly improve his health and mobility and is denied by a VAC nurse who is under investigation by the provincial nursing authority for lying, breaching the Privacy Act and Code of Conduct. The nurse stated the equipment was not related to the service related injury however, both the veterans physician and numerous provincial health personnel agree with the veterans request. The case manager then advised the veteran that “the item does not fit the grid of service benefits and VAC does not have an 'a la carte' program for equipment, suggesting that the veterans requests were erroneous. The veteran is completely disabled and unable to work. VACs mission is “to provide exemplary, client-centred services and benefits that respond to the needs of veterans, our other clients and their families, in recognition of their services to Canada”.
1. Assessment (17): In assessing numerous cases VACs main purpose is to follow specific procedures which limit or deny equipment and treatments which would significantly improve the health, safety and mobility of severely disabled veterans regardless of provincial health personnel recommendations. VAC is, for all intensive purposes, an accounting department and its personnel, in particular case managers, continuously denying requests instead of working with veterans to address their needs. Recommendation (17): VAC implement a procedure when special equipment or treatments are denied, are immediately reviewed with the veteran by senior managers or directors. This would allow VAC to follow its stated mission, ensure veterans health and needs are properly addressed.
8. Veteran leaves 45 messages with Ministers office before Minister office responds. Following 45 messages, a ministers aid then contacted the veteran and in less than two hours the aid declared all of the veterans concerns had been addressed and in his opinion “if you have concerns you can always approach the minister, and as one of his staff I have returned your call at his direction, that is the way the system is set up, so in my opinion the system seems to have worked pretty well for you so far.” The veteran advised the aid that he had contacted the Minister of Veterans Affairs Office on 45 occasions over a 5 month period prior to the aid contacting him. The veteran then asked the aid if this constituted “the system seems to have worked pretty well for you so far.” The aid did not respond tot the question. In contacting an Area Director, it was stated “we know that we are lousy frankly ... 5 years ago we were expected to cease to exists ... no investment was made in technology, no investment was made in hiring the people we needed in the long term ... as it stands right now we are very chopped up .. the way we were set up assumes we are only every going to deal with the 90 year old client, the meds needed for his dementia and being place in long term care. So that's how we were set up. This more complicated case, not going so well.” In comparison, the Minister of National Defence, personally responded to a veteran regarding a number of issues within 60 days via email and a detailed personal letter.
1. Assessment (18): Veterans Affairs is critically short of skilled personnel at all levels, which impacts upon the health and safety of veterans. VAC is a reactive organization which, unless given a reason to respond, ignores veterans needs and requests. Recommendation (18): VAC personnel at all levels begin conversing with veterans to address concerns. Personnel, even in the accounting department, should be able to directly address payment issues without involving case managers and VAC Operators. By removing the impediments to communication between veterans and the various departments within VAC, a smoother, and more responsive transition can be achieved which positively affects veterans.
9. Veteran denied access to catheter and supplies. In reviewing numerous cases, one was investigated and according to the veteran, VAC personnel denied reimbursement for catheters and supplies in accordance with a prescription from his physician and approval from provincial health personnel. The veteran received one shipment of catheters and was advised he would have to pay for the supplies while he waited for reimbursement from VAC. Subsequently, he was denied reimbursement and is not able to follow the medical treatment plan advised by provincial health authorities through a specific medical supplier. VAC denied coverage quoting 'non-benefit items' and more information required which was provided by the pharmacy.
1. Assessment (19): VAC accounts payable personnel are poorly trained and refuse to review the clients file which contains the information establishing the need in relationship to the veterans injury. Recommendation (19): When VAC rejects a reimbursement claim, the information should be sent immediately to the case manager to review and obtain the necessary information to process the claim, then a secondary manger should sign off on the secondary review prior to resubmission. In addition, the veteran should be immediately advised of the rejection and review by the case manager.
10. Treatment provider given different authorization than the veteran. Investigating differences between pre-authorizations provided to a veteran and his physiotherapist revealed a significant difference. The veteran was advised in writing that his physiotherapy treatment was authorized for a 3 month period and to continue treatment an assessment would be required by the physiotherapist. The physiotherapist was approved in writing for treatment which contained an expiry date of 1 August 2014, a 20 month period. In addition the Manager for VACs Treatment Authorization Center advised the physiotherapist they also authorized $350 to generate an assessment. The veteran is not located in Quebec however the authorization was based on a Quebec benefit code for $30/hour allowing 12 hours to complete the report. In addition, a benefit code from Quebec is higher than the benefit code for the province the veteran lives in at $25/hour. When the veteran requested pre-authorization for an assessment by a Registered Massage Therapist he was advised VAC would pay only $32.50.
1. Assessment (20): VAC deliberately misled the veteran regarding the pre-authorized treatment period. In addition, VAC was found to be providing preferential treatment to specific providers using incorrect benefit codes and unusually lengthy time periods to generate an assessment. There is no other logical explanation for providing such a large financial gains to the physiotherapy company other than entice the therapist into completing a report for forwarding personal information to VAC without the veterans consent. There is also no logic behind the difference in costs for generating a physiotherapy report versus a Registered Massage Therapist report. Recommendation (20): The Manager of the Treatment Authorization Centre, the case manager and the physiotherapy company be investigated for collusion and suspected fraudulent activity. The report fees for physiotherapy and massage therapy should be reviewed and similar costs be assigned for each assessment or report. Copies of the pre-authorizations for treatments and reports sent to the physiotherapy companies should also be forwarded to the veteran.
Veterans Affairs Canada is not designed to help the current type of veterans now in need of treatment and benefits as a result of a broad range of service related injuries. According to VAC it is designed for the 90 year old veteran who requires meds for dementia and long term care and admits they are lousy at what they do. VAC protects the privacy of its personnel above that of its clients and acts as front line health care providers without the ability to respond 24x7 leaving veterans in life threatening situations. With little or no health care training, VAC personnel make decisions which place the lives of veterans at risk.
The mission statement of VAC does not reflect the reality of its operations. VAC operates as an accounting department, seeking to safeguard its budget and resources and consistently demonstrates little or no regard for veterans health and safety. Its policies and procedures have no checks and balances as discovered in many of the situations included in this report. It is particularly disturbing to discover that VAC deliberately insulates itself from its clients through the use of covert units, provides false and misleading information to veterans, and has difficulty communicating internally and externally. VAC provides contradictory information to clients and consistently disregards the Privacy Act to collect information for purposes other than those stated.
Of all the departments and large corporations this author has worked with, VAC has the most potential to make significant improvements if it will open itself to criticism, begin communicating with veterans at all levels and implement simple, but effective recommendations allowing it to operate similar to other departments and health organizations. This report provides 20 recommendations based on actual situations:
1. Proactively screen newly approved veterans for special authorization medications and initiate approvals.
2. Advise veterans of medical suppliers who are having challenges dealing with VAC.
3. Train VAC personnel regarding submitting original receipts for reimbursement.
4. Train VAC personnel regarding the collection and use of personal information under the Privacy Act in accordance with the Treasury Board Secretariat Guidelines.
5. Case managers should advise clients of approved treatment benefits immediately with a phone call they are time sensitive.
6. VAC medical personnel should contact veterans physicians who have generated medical reports which are unclear or highly technical.
7. VAC case managers should contact CF personnel to verify injuries are service related.
8. VAC Adjudicators should contact specialist physicians to clarify the nature of the injury.
9. Veterans should be given the opportunity to discuss their case with covert units and case managers prior to decisions being made.
10. VAC Operators should forward calls to the requested VAC employee without screening, inquiring as to the nature of the call and other questioning.
11. VAC implement a discretionary dollar limit for approvals below $100 (for example) based on veterans explanations and evidence.
12. When benefits are reduced, a supervisor, manager or area director, depending upon the amount of reduction, should review and sign off on any reduction.
13. VAC develop an investigation department to review complaints by veterans.
14. VAC should transfer employees who are intentionally impeding the benefits of veterans to areas with no involvement with clients.
15. VAC Special Authorization Units should be disbanded and all medications approved. If it is suspected that medications are not related to service-related injuries, case managers should request information from a veterans physician verifying it is related to a list of conditions contained in the letter. Only after it has been established that the medication is not related should the medication be denied to a veteran.
16. VAC operators stress and frustration must be reduced by allowing them to provide the direct numbers of VAC personnel.
17. VAC implement procedures for special equipment and treatments which are initially denied be immediately reviewed by senior managers or directors prior to advising the veteran.
18. VAC personnel at all levels begin conversing with veterans to address concerns and needs.
19. When VAC rejects a reimbursement claim, the case manager should immediately review and if possible, obtain the necessary information to approve the claim followed by a secondary manager or director to sign off on the claim prior to resubmission.
20. Investigations should be undertaken when inconsistencies are discovered between information provided to the veteran and the treatment provider.
For more information:
Intelligence Officer (Retired, Head of Military Intelligence)
About the Author
Glen Gieschen is an internationally known spokesperson, intelligence specialist, and professional security consultant with 21 years of experience. He has spoken at numerous security conferences in the United States and Europe and has conducted seminars across Canada for the Royal Bank's top corporate clients and account managers. He has been interviewed by the CBC, Voice of America and other global media outlets, and his work has been presented to US Congressional hearings and appeared in more than 160 articles by the BBC, CTV, CBC, World Intellectual Property Organization, the World Economic Forum, Security Management, industry and media publications in 30 countries.
Mr. Gieschen spent 11 years as the Security Manager for Goldstar Business Forms, a security provider for high value documents. He lead the development and commercialization of security technology and was a fraud consultant and subject matter expert to clients and financial institutions for investigations, vulnerability and threat assessments, and detection and prevention strategies.
For 5 years Mr. Gieschen maintained the role of Director for the Central Intelligence Network for Counterfeiting And Piracy (CINCAP), a global network of 600 individuals in 53 countries which included intelligence, law enforcement, customs, military, corporations and security providers. He developed systems and contacts to gather, analyze and disseminate $7.6 trillion worth of incident reports.
Mr. Gieschen spent his last 3 years working as an Intelligence Officer for the Canadian Forces. He was posted to 6 locations and 4 different positions in 2 1/2 years which include the Assistant to the Assistant Chief of Staff (ACOS) of LFWA, the Intelligence Officer in charge of Training Intelligence Officers at 6 Intelligence Company and the Head of Military Intelligence for 41 Canadian Brigade Group. As the the head of military intelligence he briefed the commander and senior staff regarding threats to the CF and developed and implementing the PICARD program (Primary Intelligence Collection Analysis and Reporting Database) used to manage the intelligence cycle. He was also asked to join the special forces.