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[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

                     PARTNERING, PAYMENT, AND PROVIDER ACCESS: 
                      VA COMMUNITY CARE IN NORTH CAROLINA

=======================================================================

                             FIELD HEARING
                            Fayetteville, NC

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         FRIDAY, MARCH 23, 2018

                               __________

                           Serial No. 115-55

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
                     
                     
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           C O N T E N T S

                              ----------                              

                         Friday, March 23, 2018

                                                                   Page

Partnering, Payment, And Provider Access: VA Community Care In 
  North Carolina.................................................     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman.................................     1
Honorable Neal Dunn, Member, U.S. House of Representatives.......     2
Honorable Richard Hudson, Member, U.S. House of Representatives, 
  (NC-8th).......................................................     3
Honorable Robert Pittenger, Member, U.S. House of 
  Representatives, (NC-9th)......................................     4

                               WITNESSES

David W. Catoe FHFMA, Assistant Vice-President, Patient Financial 
  Services, Atrium Health........................................     6
    Prepared Statement...........................................    30
Sarah Verardo, Executive Director, The Independence Fund.........     8
    Prepared Statement...........................................    31
Staff Sergeant Gary B. Goodwin (Ret.), Veteran, U.S. Army........    11
    Prepared Statement...........................................    33
Chief Master Sergeant Daryl D. Cook, Chief, Fire Emergency 
  Services, 145th Civil Engineering Squadron/Civil Engineering 
  Flight, North Carolina Air National Guard......................    13
    Prepared Statement...........................................    36
DeAnne M. Seekins MBA, Network Director, VA Mid-Atlantic Health 
  Care Network (VISN 6), Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    14
    Prepared Statement...........................................    37

        Accompanied by:

    Mark E. Shelhorse M.D., Interim Medical Center Director, 
        Fayetteville VA Medical Center, Chief Medical Officer, VA 
        Mid-Atlantic Health Care Network (VISN 6), Veterans 
        Health Administration, U.S. Department of Veterans 
        Affairs

    Joseph Enderle, Program Manager, Veterans Choice and VA 
        Timely Payment Initiative, Delivery Operations, Office of 
        Community Care, Veterans Health Administration

 
 PARTNERING, PAYMENT, AND PROVIDER ACCESS: VA COMMUNITY CARE IN NORTH 
                                CAROLINA

                              ----------                              

                         Friday, March 23, 2018

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:00 a.m., at 
the Fayetteville Technical Community College, General Classroom 
Building Rooms 108 and 114, 2817 Fort Bragg Road, Fayetteville, 
NC, Hon. Phil Roe [Chairman of the Committee] presiding.
    Present: Representatives Roe and Dunn.
    Also present: Representatives Hudson and Pittenger.

          OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN

    The Chairman. The Committee will come to order.
    Good morning. I want to thank all of you all for being 
here. I want to give a special shout-out to Dr. Larry Keen, who 
is President of the community college here, for allowing us to 
use this great facility, and I want to thank all of you all who 
are here.
    This is an official hearing of the Veterans' Affairs 
Committee, and I really enjoy these because it is actually 
where we bring the government to the people, not the other way 
around. I have done many of these around the country and have 
found them very beneficial.
    My name is Dr. Phil Roe, and I represent Tennessee's 1st 
Congressional District, which is just across the line from you 
guys. I am a taxpayer in North Carolina, so I think I feel 
welcome here.
    [Laughter.]
    The Chairman. I have a condo in Banner Elk, so I pay taxes 
in your great state.
    Tennessee's 1st Congressional District is a very historic 
district. It is the only district in America that has had two 
presidents, Andrew Jackson and Andrew Johnson. Andrew Johnson 
was the first person to hold my seat, and we had one other 
famous Tennessean who held my seat, and we have all watched him 
on TV. Davy Crockett was a congressman from the 1st District, 
and I am honored to serve as the Chairman of this great 
Committee, the Veterans' Affairs.
    I would like to start today by thanking Congressman Hudson 
for his enthusiasm for hosting this veteran-specific hearing 
today. We have been forced to reschedule this hearing a couple 
of times, and I told Richard on Monday, I said this looks like 
another train wreck that is about to happen with the budget. 
But, Richard, thank you for hosting this.
    He has been a true champion for veterans in Washington, 
D.C., and I am honored to be here with you today and to deep 
dive into the issues and problems.
    I also want to thank Congressman Dr. Neal Dunn, who is a 
veteran, as I am, who serves on the Veterans' Affairs 
Committee. Neal is a pretty old looking freshman, but this is 
his first term.
    [Laughter.]
    The Chairman. I, too, was a very old freshman. And also, 
one of your own, Robert Pittenger, who is also joining us. 
Robert and I have been great friends since he has come to 
Washington.
    Dr. Dunn is both a surgeon, as I said, and a veteran, and 
he serves along with me. He shares my desire to bring both 
private-sector efficiencies and high-quality health care to the 
VA to our veterans.
    Congressman Pittenger represents North Carolina's nearby 
9th Congressional District and literally jumped at the 
opportunity to join us at this field hearing for nearly 150,000 
veterans living in this area, and I thank both of you all for 
joining us.
    In this part of the country, as is the case in my backyard, 
over the mountains, veterans often face extraordinary burdens 
in receiving VA health care, whether at VA facilities or 
through an overly complex administrative system of non-VA 
authorizations.
    My goal for this hearing is to identify opportunities for 
VA to build and improve upon its relationship with local health 
care entities and hopefully reduce the burden we ask these 
veterans and local providers to endure.
    I also hope to gain a better understanding of what 
resources and support of VA facilities and staffing 
requirements are needed for the provisions of appropriate and 
timely care in this part of North Carolina. Let's take this 
opportunity to look towards the future needs of veterans who 
live here to improve the access to and the quality of their 
care, and discuss what steps VA can take today to strengthen 
community partnerships and team with providers who are also 
eager to serve veterans in this catchment area.
    Before we begin, I ask unanimous consent that Congressmen 
Hudson and Pittenger be allowed to join our Committee 
proceedings today.
    Without objection, so ordered.
    With that, I will yield to Dr. Dunn of Florida for 5 
minutes for any opening remarks that he may have.
    You are recognized.

            OPENING STATEMENT OF HONORABLE NEAL DUNN

    Mr. Dunn. Thank you very much, Mr. Chairman. I will not 
consume 5 minutes. I just want to say and also convey a thank-
you to my friend and colleague, Representative Hudson, for 
inviting me back to Fayetteville. I have known Rich as a very 
strong advocate for the active-duty troops and for the veterans 
in his district, and indeed across the country in the time I 
have been in Washington, and I thank you very much for your 
tireless efforts. Rich took me to Afghanistan a few months ago, 
and we spent Thanksgiving there serving the troops, and it was 
a great experience for me.
    I was stationed here at Bragg twice in my military career, 
and it is great to come back. It seems like you always come 
back to Fort Bragg. There is something funny about that.
    I do also want to say thank you to the House Veterans' 
Affairs staff that has worked very hard to put this together. 
It is always a little extra work to put together a hearing on 
the road, but it is worth it. We absolutely know, we have 
demonstrated time and time again that we have to come out here 
and listen to you, we can't just have people come to Washington 
and talk to us. So I am very, very grateful for that 
opportunity.
    With that, I will also say thank you to my good friend, 
Robert Pittenger, who is a local congressman right here.
    With that, I will yield back my time.
    The Chairman. I thank the gentleman for yielding.
    I now recognize Representative Hudson for any opening 
remarks he may have.

         OPENING STATEMENT OF HONORABLE RICHARD HUDSON

    Mr. Hudson. Well, thank you, Chairman. I appreciate this 
opportunity and welcome everyone here today. I want to 
particularly thank the Chairman for agreeing to host this 
hearing here in our community. We have no stronger advocate on 
behalf of our veterans than Dr. Phil Roe, Chairman of the 
Veterans' Committee. He is just tireless, he himself, for being 
a Vietnam-era veteran, and he has been very successful in 
getting legislation to President Trump to help our veterans. He 
is a tremendous leader, and it is just an honor to have you 
here with us, Mr. Chairman.
    I also want to thank Congressman Dunn for being here. As he 
said, he and I traveled to Afghanistan over Thanksgiving, where 
we spent some time with folks from 82nd Airborne down to 
Kandahar and some other places we can't tell you about, but it 
was really an honor to be there with the troops. Dr. Dunn has a 
real heart for our soldiers, and welcome back after serving two 
tours here himself as an Army surgeon.
    I also want to thank Congressman Pittenger for being here. 
Robert Pittenger works hand in hand representing this 
community. Robert Pittenger cares deeply about our veterans. I 
have seen the work he does on veterans' behalf, and I am proud 
to stand shoulder to shoulder with Robert, and I appreciate you 
being here with us today.
    We also have two outstanding senators here in North 
Carolina, Senator Burr and Senator Tillis, who I lean on all 
the time to help me with veterans' cases. When they get tough 
and I run into a roadblock, I call one of the two senators and 
they usually break it for me. They are represented today. 
Austin Sheer is here from Senator Tillis' office, and Janet 
Bradbury representing Senator Burr, and we appreciate you all 
being here with us.
    Each and every one of us is here today because we truly 
care about our Nation's veterans. It is impossible to ever 
repay our veterans for the service and the sacrifice, so 
ensuring that we keep our promises that every veteran is 
provided with the care they deserve is the most sacred 
responsibility I have.
    My greatest honor in life is I represent 54,000 men and 
women at Fort Bragg and the families and the veterans in this 
community. Simply put, these individuals represent the best 
among us, the best our Nation has to offer. Every year, more 
and more veterans are choosing to relocate or stay right here 
in North Carolina after their service, and I think that is a 
good thing, but it is also a challenge. We have the fastest 
growing veteran population, the fastest growing VA in the 
country. That brings us both opportunities and challenges, but 
it is something that we are proud of.
    But veterans have been provided opportunities to interact 
with a very tight-knit military community here, and businesses 
are able to capitalize on the expertise of hiring veterans. So 
I think it is a tremendous opportunity. However, the challenges 
that come along with this rapidly growing veteran population, 
one of these challenges is meeting the unique needs of veterans 
when it comes to health care.
    Generally speaking, I believe the Fayetteville VA Medical 
Center does an exceptional job at taking care of the veterans 
who seek treatment there. Many of the folks who work there are 
veterans themselves. However, there is no way that they alone 
can provide all the care in a timely fashion to the veterans of 
this community and meet this growing population. That is why it 
is critical we continue to work to improve the relationship 
between the VA and medical providers in the community, so 
veterans have the choice to receive care within the VA system 
if they choose, or from a community provider that may better 
suit their unique needs.
    Every case is different, which is why a one-size-fits-all 
approach will never work. Since coming to Congress, I have 
worked to expand the ability of veterans to choose their health 
care provider, whether that be within the VA or in the 
surrounding community. I have legislation called The Care 
Veterans Deserve Act that does just that, and many of the same 
principles have been incorporated in the Chairman's 
legislation, the VA Care in the Community Act, which I am very 
proud to have supported.
    I am encouraged by the Committee's efforts to simplify and 
expand opportunities for programs, and I look forward to 
continuing to work to pass meaningful reforms in Congress on 
behalf of our veterans. I am excited to hear from our witnesses 
today. I want to thank each one of you for making the time to 
be here. It is very important.
    Mr. Chairman, with that, I will yield back the balance of 
my time.
    The Chairman. I thank the gentleman for yielding.
    I will now yield 5 minutes to Representative Pittenger for 
any comments that he may wish to make.

        OPENING STATEMENT OF HONORABLE ROBERT PITTENGER

    Mr. Pittenger. Thank you, Chairman Roe. I certainly 
appreciate and respect your leadership for the veterans. You 
are doing an extraordinary job.
    I spent a little bit of time with him in the Congress, a 
little bit of time off Congress. We played a game of golf 
together.
    The Chairman. I am not very good, either.
    [Laughter.]
    Mr. Pittenger. The thing of it is, he never left the 
fairway, and I never got in the fairway.
    [Laughter.]
    Mr. Pittenger. But Richard Hudson, what a remarkable leader 
you are for veterans. Thank you for all the efforts that you 
have been through to organize this meeting; Chris, your man 
right over here, who really did the work. I have a similar man, 
Bob Becker, who is here, who serves about 400 to 500 veterans 
at any given time. So we are very much acclimated to the 
concerns.
    Dr. Dunn, thank you for making your way up here from 
Florida, and I hope you enjoy our weather.
    To each of you all, we are not coming here with an ax to 
grind. The old adage of Sergeant Friday, ``Just the facts, 
ma'am, just the facts,'' that is all we want today are facts. 
We want to know what is best for our veterans. We do believe 
that the Veterans' Accountability Act can improve that process, 
giving more authority to the director. We certainly have a good 
director here. I met him over at Landstuhl in Germany when they 
released the hostages. I was sent over there by the White House 
to greet them, and he is remarkable. I know you are going to 
have great leadership here. I think he is going to do a great 
job.
    But this is important for this community. It is important 
for our veterans. Each of us who represent them and represent 
you are here to want the best, and I know that is the interest 
of all of us. So I thank all of you for being here, for your 
expertise, for what you bring to the table, and what you will 
mean to the lives of those who served our country with 
distinction, with a great labor of love and commitment, and 
they deserve the best from us.
    God bless you.
    The Chairman. Thank you, Robert. Thanks very much.
    Before I introduce our witnesses, can you all hear in the 
back? Are we loud enough? I got an open ``yes.'' We will try, 
when the witnesses speak, we will try to speak up. I don't know 
if you can turn the mics up a little bit or not, because it is 
a large room. We will try to get where you can hear us, and I 
apologize if you cannot.
    But I want to remind everyone today that this is a formal, 
official congressional hearing. It will go into the 
Congressional Record.
    We have one panel of witnesses, and only those invited to 
testify will be permitted to speak. Each panelist will have 5 
minutes for their opening remarks, and I respectfully ask that 
our panelists keep an eye on the timer that we set for you 
here. The green light goes on, amber light at 1 minute, and 
then the red light when your time has expired.
    There will be an opportunity after the hearing for those of 
you in the audience who want to come up and speak with myself 
or other Members of our staff if you have questions or need 
assistance. We will be glad to do that.
    Joining us on our first and only panel this morning is Mr. 
David Catoe, the Assistant Vice President of Patient Financial 
Services for Atrium Health; Mrs. Sarah Verardo, Executive 
Director for The Independence Fund. We first met, I believe, at 
the White House. Is that correct?
    Ms. Verardo. Yes, correct.
    The Chairman. I appreciate you being here.
    Staff Sergeant Gary B. Goodwin, retired, U.S. Army veteran. 
Thank you, Sergeant.
    Chief Master Sergeant Daryl Cook. When I went in the 
infantry, it was explained to me this way, that the command 
structure was God, command in general, and the Chief Master 
Sergeant, but not necessarily in that order.
    [Laughter.]
    The Chairman. I am not sure whether that is still the case 
or not, but I suspect that it is.
    He is the Chief of Fire Emergency Services for the 145th 
Civil Engineering Squadron and Civil Engineering Flight of the 
North Carolina Air National Guard. Welcome.
    Mrs. DeAnne Seekins, Network Director for the Mid-Atlantic 
Health Care Network, or VISN 6, for the Veterans Health 
Administration. Thank you so much for being here.
    Ms. Seekins is accompanied by Dr. Carl Bazemore, who is the 
Acting Chief Medical Officer for VISN 6 for the Veterans Health 
Administration. Also accompanying Ms. Seekins is Joseph 
Enderle, the Program Manager for Veterans Choice and VA Timely 
Payment Initiative, Delivery Operations of the Veterans Health 
Administration.
    I thank all of you all for being here today and for all the 
good work that each of you do to serve our veteran neighbors 
here in North Carolina across VISN 6.
    Mr. Catoe, we will begin with you. You are now recognized 
for 5 minutes.

               STATEMENT OF DAVID W. CATOE, FHFMA

    Mr. Catoe. Good morning. As a veteran retired Air Force 
officer, I want to thank this Committee for the opportunity to 
speak on behalf of Atrium Health, formerly known as Carolinas 
Healthcare System. Atrium Health has always had an outstanding 
relationship with our veterans in all the communities that we 
serve, and we consider it a privilege to provide their medical 
care. In fact, going back to January 2016 through February 
2018, or the past 26 months, Atrium Health has provided care on 
approximately 33,000 occasions or times that veterans have 
visited our health care system. Our health system has been 
recognized numerous times for supporting military personnel and 
veterans through awards such as the Secretary of Defense 
Freedom Award, the Secretary of Defense Patriot Award, and 
being a Top 10 Military Friendly Employer. As we work to 
further support our military veterans, I would like to take a 
few minutes to highlight some of the issues that Atrium Health 
is working to overcome in coordinating claims administration 
with the VA programs.
    First of all, medical records. Atrium Health often submits 
multiple hard-copy medical records to the VA for the same 
patient encounter due to VA being unable to locate and match 
records with the claims. This burdens hospitals 
administratively and presents potential HIPAA privacy concerns. 
However, hospitals have no other option but to continue this 
process to receive payment. In a recent random sample of 19 
claims, on average, Atrium Health had to submit medical records 
two-and-a-half times per claim. Sixteen of the 19 claims 
required records to be sent at least twice, one was sent five 
times, and four were sent four times. Other commercial payers 
have portals through which medical records and other 
documentation are uploaded to attach the claims, and this helps 
avoid printing and mailing sensitive medical record 
information. We believe it would be beneficial for VA to 
implement a HIPAA-compliant system like the other payers for 
this process.
    Second, authorizations. During the period of January 2016 
through February 2018, Atrium Health received over 2,458 
denials for claims totaling $24 million relating to 
authorization issues. As recently as two days ago, I received a 
congressional inquiry regarding an unpaid VA Choice claim 
dating back to March 2017 for a missing authorization number.
    When veterans present for medical care at Atrium Health, we 
treat them as our priority. Most veterans do not have the 
authorization number when they present, and so we have to try 
to obtain the number after the fact. Because there is both a 
clinical and claims component in the authorization process, 
there are often handoffs occurring which have led to trouble 
during claims administration. For example, VA faxes 
authorizations to a fax number in Clinical Case Management at 
our hospital. When we call the VA to obtain an authorization 
number, they often cannot provide us that number. It would be 
much more efficient and convenient for everyone if the VA could 
establish a payer portal so that authorizations could be pulled 
by the provider electronically and added to the claim. This 
would eliminate unnecessary calls to the VA for the 
authorization number and improve the service to our veterans.
    Third, excessive hold times. Atrium Health claims 
specialists experience excessive hold times when calling for 
claims status. It is not uncommon to be on hold from 25 minutes 
to three hours before reaching a claims representative. For VA 
Choice claims, we are only allowed to ask about three claims at 
a time before having to hang up and call back and repeat the 
entire waiting process to follow up on additional claims. We 
have also had to leave phone messages and emails with provider 
relations in the past since we could not contact a live person, 
but rarely do we ever receive a reply call. The claims 
specialists at Atrium Health who work VA claims are often 
frustrated and demoralized due to the stress encountered as 
their productivity diminishes when spending so much time 
waiting for assistance. More VA claims representatives are 
needed to eliminate the volume of calls and the excessive wait 
times. The average wait time for a VA claims specialist is 60 
minutes on 10 accounts reviewed in February and March. The 
longest was 110 minutes, while the shortest was 25 minutes.
    Education. VA needs to provide better education to the 
providers and veterans in explaining the different requirements 
and programs available. Currently, these programs are very 
confusing to even an experienced VA claims specialist. I cannot 
imagine the confusion that many veterans experience in trying 
to coordinate their care within the VA. An excellent example is 
the Other Health Insurance amended regulation dated January 
9th, wherein VA advised that providers must bill other health 
insurance before the VA, and then the VA may be billed 
secondary to the other health insurance for emergency services.
    VA is an entitlement and not an insurance program. By law, 
it is prohibited from paying deductibles, co-insurance, and co-
payments incurred by billing the other health insurance. Yes, 
veterans still believe the hospital has the option to bill VA 
over other health insurance, and they blame us, of course, when 
the veteran is required to pay a $1,000-plus deductible when we 
bill the other health insurance, saying we should have billed 
VA first. With more communication, awareness, and education 
about the programs, there should be less confusion and more 
efficiencies in place to better serve our veterans.
    Again, thank you for allowing me the privilege to discuss 
some of the opportunities that our health system believes can 
improve our veterans' experience as we provide medical care and 
the subsequent filing of claims with the VA. We are pleased to 
work with you and the VA to make the claims process more 
streamlined, efficient, and friendlier. Thank you.

    [The prepared statement of David N. Catoe appears in the 
Appendix]

    The Chairman. Thank you, Mr. Catoe.
    Ms. Verardo, you are recognized for 5 minutes.

                   STATEMENT OF SARAH VERARDO

    Ms. Verardo. Thank you for having me, Chairman Roe, and 
providing the opportunity to testify. I am Sarah Verardo, 
Executive Director of The Independence Fund. Our national 
headquarters are here in Charlotte, North Carolina.
    I want to give special thanks to Representative Hudson for 
recommending that we testify today. He is an amazing friend to 
The Independence Fund and the strongest of champions for 
veterans here in North Carolina, and likewise I would say the 
same about Representative Pittenger. Both men have been 
incredible friends to my family, to my husband. Representative 
Hudson has followed his journey since Walter Reed, and I think 
few people were more excited to see my husband walking than 
Representative Hudson, so I sincerely thank all of you.
    Mr. Chairman, I have submitted a much more extensive 
written testimony to your staff, and I ask, sir, that it be 
entered into the record in its entirety, please.
    The Chairman. Without objection.
    Ms. Verardo. On April 24th, 2010, my husband, Michael 
Verardo, was catastrophically wounded by an IED in southern 
Afghanistan. His left leg and arm were immediately blown off. 
While he was dragged to the casualty collection point, the IED 
continued to detonate daisy-chain style, resulting in a large 
area of third-degree burns over 30 percent of his body. He 
suffered a lot of facial trauma. The IED was an old Russian 
landmine that the Taliban had connected to two 15-gallon jugs 
of homemade high explosive. The debris within the IED blew out 
his eardrums, caused severe facial damage, and he wasn't 
expected to survive. He had a field non-FDA-approved blood 
transfusion to stay alive.
    When a servicemember is injured, there are several 
classifications of the medical evacuation: not seriously 
injured, seriously injured, or very seriously injured. Mike's 
Medevac was called in as very seriously injured, expected dead 
on arrival. He was not expected to live. He remained in a coma, 
but he is a fighter, and for the next five weeks he was listed 
as death imminent.
    Through incredible efforts of Army medical teams, not only 
did Mike survive, his left arm was reattached partially and 
reconfigured. He eventually learned to walk on a prosthetic 
leg, and now we live outside of Charlotte, North Carolina with 
our three young daughters.
    While Mike was not retired from the Army until 2013, I must 
say the Army medical care and the DoD care within the Warrior 
Transition Battalion at both Walter Reed and Fort Sam Houston 
was incredible. He endured over 100 surgeries and years of 
speech, visual, physical, and occupational therapies, and he 
thrived. There were no bureaucratic hurdles within our DoD 
process.
    Unfortunately, the same cannot be said for our transition 
to VA care. While most of the medical providers we have had 
have been exceptional, first rate, the medical administration 
staff with whom we usually deal appeared disinterested, 
skeptical of medical requests, more concerned with preventing 
fraud than allowing common sense to prevail, and not interested 
in optimizing veteran health care.
    For example, after Mike retired from the Army, we moved 
back to our home state of Rhode Island, and despite being rated 
by the VA with the highest possible rating and being enrolled 
in VA health care, no one in VA knew we were coming back to 
Rhode Island or who Mike was, and we had to wait seven weeks 
for our first appointment even though he still had open wounds, 
a poly-trauma case, and exceptionally complex medical regimes. 
I went on YouTube to learn how to re-pack his wound dressings 
myself, and I had a fire department bring him in and out of the 
home because we had not been set up with any type of specially 
adaptive housing from VA.
    In the same vein, Mike's prosthetic leg was damaged, and we 
waited 57 days for a signature on a form authorizing it. In the 
meantime, I duct-taped his leg back together.
    The catastrophically wounded and disabled veterans we serve 
at The Independence Fund have similar stories of the VA health 
care system. We believe much of this is because VA standards of 
care and formularies do not take into account the complex 
issues of the catastrophically wounded. Therefore, Mr. 
Chairman, we recommend any future legislation to define when 
and where veterans are eligible for non-VA care. They should 
establish separate specific access and quality standards for 
catastrophically disabled, where they qualify for non-VA care, 
even if the standard access and quality standards are otherwise 
met.
    Mr. Chairman, we share your disappointment. The compromise 
VA and caregiver reform legislation you helped negotiate and 
you championed was rejected by the minority Members of the 
Committee. However, we were concerned that both bills 
originally passed by the House and Senate Veterans' Affairs 
Committees still relied on VA to determine when and where 
veterans can access non-VA care. Again, our experience is the 
medical administration bureaucracy will block most attempts of 
medical providers to prescribe non-VA care and only will 
authorize it if forced to do so.
    I would like to give you another example about my husband 
for that point. His residual left leg suffers numerous skin 
injections that make the prolonged use of prosthetic sleeves 
extremely dangerous for him. Because of that, his VA surgeon 
prescribed within her own hospital system a specialized 
prosthetic sleeve nine different times, and nine times VA's 
medical administrators, who have never met or treated my 
husband, denied those prescriptions because they were not 
formulary.
    Mr. Chairman, we cannot rely on VA health care providers 
being able to prescribe non-VA care when needed. Those VA 
health care providers are powerless to provide non-VA care when 
the bureaucrats have every incentive to deny the care and have 
every power to do so, far more than the actual providers who 
are taking care of these heroes. Only when individual veterans 
have the authority to choose their own health care provider 
will veterans be able to access optimal care in a timely 
fashion.
    Finally, we believe that VA's prosthetic and wheelchair 
repair/replacement program should be out-sourced to non-VA 
providers. Our experience and that of our clients is that the 
VA doesn't deliver or make attempts to deliver wheelchair and 
prosthetic repairs in a timely manner. For example, we have 
requested wheelchair and prosthetic repairs and replacements 
from VA, and I have been told four different times within this 
VISN that I must bring my husband three hours round trip so 
that they can confirm that he does, in fact, still have his 
injuries, as though limb loss would be anything other than 
permanent. Delays of seven to ten weeks are not unusual for 
these requests.
    We note the Inspector General report released a week ago 
detailing similar problems with wheelchair and prosthetic 
repairs in VISN 7. That report noted the VA has no standard for 
how long it should take to repair wheelchairs or scooters, no 
standard at all. It also found the average wait time was 99 
days. Some of these veterans were bedridden for more than 100 
days while waiting.
    The report detailed an unnecessarily complex repair 
authorization process. We recently had the opportunity to meet 
with VA Central Office, and we are looking to enter into a 
Memorandum of Understanding with VA to help them improve those 
processes, and we would love your support, sir, in doing so.
    We do not believe that VA will ever be able to adequately 
respond to veterans' prosthetic and wheelchair replacement 
needs in a timely manner. The rules are simply too cumbersome 
and limiting, and we recommend that veterans be allowed 
immediate access to non-VA care for the repair or replacement 
of prosthetics, wheelchairs, and scooters.
    I would like to end, sir, by telling all of you that you 
will notice how often in society people say that something 
costs an arm and a leg, and my husband's military service 
actually did. I will live forever with the consequence of him 
raising his hand and saying, ``Send me.'' My children will live 
with that consequence of him giving almost everything he has of 
himself at 25 years old, becoming eligible for nursing home 
care, and here we are nearly eight years later, and our days 
will never be normal, they will never be stable. The terrorist 
enemy took so much from my entire family and our future.
    So, sir, I am not only here as the Executive Director of a 
very large national veteran service organization but as a 
military spouse and veteran caregiver, begging all of you to 
please keep pushing until we get it right for heroes like my 
husband, and I thank you.

    [The prepared statement of Sarah Verardo appears in the 
Appendix]

    The Chairman. Thank you for your very compelling testimony, 
Ms. Verardo.
    Sergeant Goodwin, you are recognized for 5 minutes.

          STATEMENT OF STAFF SERGEANT GARY B. GOODWIN

    Sergeant Goodwin. Thank you, Mr. Chairman and Members of 
the Committee present today. It really is an honor for me to be 
here today to offer testimony. I previously offered written 
testimony, and I ask that be entered in the Congressional 
Record.
    The Chairman. Without objection.
    Sergeant Goodwin. Thank you, sir.
    My name is Gary Goodwin. I am a veteran of the United 
States Army, having retired in 2009 after 23 years of service. 
Before I offer brief testimony, I want you all to know that my 
issues today are in no way with the quality medical care that I 
receive from the Fayetteville VA Medical Center. For those 
representatives of the VA Medical Center, and I know our new 
director is present as well, I want to say thank you. I am 100 
percent happy with the quality care that I receive from that 
facility. I think it is a shame that the media tends to zero in 
on the negative and not accentuate the positive.
    I also want to say, Ms. Verardo, thank you so much for you 
and your family. I almost feel ashamed to be here today--
    Ms. Verardo. No, please.
    Sergeant Goodwin [continued].--to offer my testimony, 
having heard your compelling story. My heart goes out to you 
and your family. It really, really does.
    Also, I want to thank my primary care provider here at the 
VA Health Care Center, Dr. Abul Azad. Dr. Azad has been my 
primary care provider for several years now. He is a great man, 
he is a wonderful physician, and he provides me with care and 
compassionate service every time I am there, as well as two of 
his nurses who I became very familiar with, Ms. Lillian 
Figueroa and Ms. Tracy Ford. I always enjoy seeing them 
whenever I go to the VA Health Care Center for my care.
    The past four years have been kind of medically challenging 
for me. I underwent three major surgeries, two minor 
procedures, numerous hospitalizations, and countless ER and 
urgent care visits. This includes experiences not only directly 
with the VA Health Care Center here in Fayetteville, but I have 
also received services through Veterans Choice, as well as non-
VA care. So I do have a familiarity with those programs as 
well.
    But I was asked to speak to you today by Congressman 
Hudson--and thank you, sir, for asking me to come today--
regarding a specific issue that has not yet been 100 percent 
resolved. If you will bear with me, I will just go ahead and 
read from my documentation.
    I have encountered an issue with the VA that I have been 
unable to resolve on my own after repeated attempts to do so, 
and this is regarding non-payment of non-VA medical expenses 
that have been approved by the VA for payment. I am offering 
testimony regarding this issue as I can only imagine that I am 
probably not the only veteran who has ever encountered this 
problem.
    On July 22, 2016, a Friday evening, I sought ER care at a 
non-VA facility for issues related to a recent thoracic 
surgery. I followed the appropriate procedures and notified the 
Fayetteville VA Medical Center the following Monday, July 25th, 
to let them know that I had this non-VA care, that it was 
follow-up care within the 90-day global window of the thoracic 
surgery that I recently had that had been--I had been sent out 
to a local hospital from the VA to have that procedure. After 
several inquiries to the VA, I finally received a letter from 
the Fayetteville VA, dated January 13, 2017, stating that my ER 
visit, that that had been verified as an episode of care, which 
is the kind of language that they use, and also that my claim 
had been approved by Salem, referring to the Salem VA office 
where the payment was coming from, and that payment was 
pending.
    Well, I can tell you, as of last Friday, after several 
inquiries, the bills for the emergency room, the emergency room 
physician, and the emergency room radiology service have 
finally been paid. That just occurred within the last week and 
a half to two weeks. The bill that is outstanding, the one that 
I contacted Mr. Hudson's office about, was the EMS bill. The 
EMS provider had never been paid by the VA. They took my 
account to collections. From there, they initiated garnishment 
against any North Carolina tax refund. And when they sent me to 
collections, all of a sudden, my credit score with the credit 
reporting bureaus went from 820 to 670. In today's world, 
credit makes the world go around, and you can't get a loan for 
a box of doughnuts when you have a credit score of 670.
    I have made repeated contact attempts. I have my file 
documentation here of all the phone calls, emails, face-to-face 
meetings with personnel at the Fayetteville VA Medical Center, 
and the non-VA care office regarding this issue, and they have 
all been very helpful. I think it is really the bureaucracy 
that has kind of tied their hands.
    Last Friday, I had a conversation with the VA 
representative in the non-VA care department, and they were 
telling me that that bill had been approved for payment, but it 
was sent to Texas. When I inquired, ``What do you mean by sent 
to Texas?'' nobody could offer me any type of an explanation. 
As a matter of fact, the gentleman I was speaking to got rather 
frustrated with me, as though my inquiries were kind of hitting 
the hot button with him.
    So, in a nutshell, that is what I am here about today, just 
to offer you testimony regarding my personal experience. I look 
forward to working with the VA regarding this issue, and I am 
hopeful that in the very near future the VA is going to attend 
to the EMS bill that they previously told me in writing they 
were going to pay for, and I hope they are going to stand by me 
to help restore my good credit.
    Mr. Chairman, with that, thank you.

    [The prepared statement of Sergeant Gary B. Goodwin appears 
in the Appendix]

    The Chairman. Thanks, Sergeant Goodwin.
    Sergeant Cook, you are recognized.

        STATEMENT OF CHIEF MASTER SERGEANT DARYL D. COOK

    Master Sergeant Cook. Good morning, Chairman Roe, Dr. Dunn, 
Congressman Hudson, Congressman Pittenger, and Members of the 
Committee on Veterans' Affairs. It is truly a pleasure to be 
provided with the opportunity to share experiences as it 
relates to the Veterans Administration and, more importantly, 
share many positive experiences. I will also provide some 
issues within the program I feel are recommended areas of 
improvement. While I continue to serve as the Installation Fire 
Chief assigned to the 145th, my testimony is my views and not 
those of the 145th Airlift Wing or the North Carolina National 
Guard.
    As mentioned, I serve as the Installation Fire Chief to the 
145th Airlift Wing in Charlotte, where we respond mutually with 
Charlotte Fire Department to emergencies at Charlotte Douglas 
International Airport, the sixth busiest airport in the 
country. Additionally, our mission includes providing emergency 
services for Stanly County Airport near Albemarle, North 
Carolina. I have 32 drill status Guardsmen and 24 North 
Carolina state employees to assist in providing coverage for 
these locations.
    With varying personnel between military and civilians, I 
have the opportunity to serve with many individuals who deal 
with the Veterans Affairs, and typically information I receive 
is positive in nature. Close to 100 percent of my personnel 
have deployed, so many have direct interaction with the VA 
prior to and after their deployments. Most of the information I 
receive is positive, but as with any program, improvement in 
the process and the overall goal of providing the best care to 
our veterans can always get better.
    I would like to just highlight a few of the folks that I 
have dealt directly with on their experiences. And again, most 
of these are positive in nature, but I will highlight a few 
issues that we have had in the system.
    Master Sergeant Chris Johnson, who is actively a member of 
the 145th Airlift Wing, when asked about his interaction with 
the VA, he had nothing but favorable comments about his 
experiences. Staff were very friendly and professional and 
informative with the services they provide. The facilities used 
were clean and in good condition, and he was able to receive 
referrals for things like a nutritionist and eye doctor in a 
timely fashion, and when he needed services from the Emergency 
Department in Charleston, South Carolina, they were both prompt 
and excellent in service.
    Retired Chief Master Sergeant Pete Hazleton, previously 
assigned to 145th Airlift Wing, now assigned as one of my state 
firefighters with the Air National Guard, utilizes the VA's 
medication program and primary physician program with positive 
success. He actually uses the VA there in Charlotte that is new 
and very up to date. There are difficulties and concerns in 
scheduling appointments. It takes excessive time to get 
appointments, sometimes months out, and the process for making 
appointments and getting referrals is not an easy one. When 
directed to have lab work done, it typically takes an extended 
period of time, and many times orders are not there when you 
arrive to have the labs taken.
    Finally, Master Sergeant, retired, Donald Willis, 
previously assigned to the 145th Airlift Wing, now assigned as 
one of my state Assistant Fire Chiefs with the Air National 
Guard, originally contacted the VA in January of 2017. He 
contacted the Catawba office and asked what services he could 
obtain upon his retirement. He was formally informed by them 
that finances made him ineligible for VA medical benefits. He 
retired from the North Carolina Air National Guard in June of 
2017 and went to the VA office in Charlotte in September of 
2017 and asked about retiring services for related injuries. He 
filled out paperwork, and the VA representative made an 
appointment at the VA clinic on 26 October 2017. He went to the 
appointment with his medical records that were transferred to 
the VA. He started the paperwork for the services related to 
his disability. The VA clinic made his next appointment for 26 
October 2018.
    Last week, he received a letter from the VA indicating that 
the appointment had been cancelled and provided some numbers 
for him to call to find out why. He then called VA at the 800-
number given and spoke to a representative who indeed verified 
that his appointment had been cancelled. He asked for what 
reason the cancellation, and she checked the system and said 
that it was probably because he made too much money. He did 
receive a letter from the VA telling him they were looking into 
it and would get back to him.
    In closing, I want to thank you for your concerns and 
efforts you have put forth in ensuring our veterans receive the 
best care available. I appreciate the House Veterans' Affairs 
Committee being proactive and seeking out ways to better serve 
our Nation's best. Additionally, I would like to thank those 
who have served before me, those who I have had the opportunity 
to serve with, and those who will serve after me. It is truly 
an honor to serve this great Nation. God bless this Committee, 
and God bless the United States of America.

    [The prepared statement of Master Sergeant Daryl Cook 
appears in the Appendix]

    The Chairman. Thank you, Sergeant Cook.
    Ms. Seekins, you are recognized.

              STATEMENT OF DEANNE M. SEEKINS, MBA

    Ms. Seekins. Yes. Good morning, Chairman Roe and gentlemen. 
Thank you for inviting me here today to have the opportunity to 
speak with you about veterans' health care, specifically about 
the Fayetteville, North Carolina health care system.
    I assumed the role as Network Director in July of 2017, and 
I have had the great honor of serving veterans for 34 years 
throughout this Nation at various medical facilities and 
network offices.
    The VISN 6 encompasses all of Virginia and North Carolina, 
as you may know. In this health care system we have seven 
medical centers, we have 30 outpatient clinics, we have five 
health care systems, and also two free-standing dialysis units.
    Today I would like to share with you, which Congressman 
Hudson already has, that we are the fastest growing VISN in the 
country. We have in the last 10 years, VISN 6 alone has grown 
by 118 percent, and Fayetteville has grown by 70 percent in the 
last 10 years, and those are veterans seeking treatment.
    VISN 6 also has many veterans who live in a rural setting, 
and out of the 19 counties that are served by Fayetteville, 17 
of those counties are deemed rural or highly rural. So to meet 
the demand, VISN 6 has had the opportunity to open five new 
health care centers in the past four years. All of these health 
care centers have been within North Carolina.
    Fayetteville alone has added 420,000 square feet to its 
existing space and also hired 841 new staff members. So we are 
making all the attempts that we can to meet the growing demand 
of our veterans.
    I would be remiss if I didn't thank each and every one of 
you. It is your support that has allowed us to have the 
appropriate approvals so that we could open these health care 
centers in this highly populated and growing veteran 
population.
    We also, with your support, have been given approval to 
open three additional health care centers, and one of those in 
North Carolina.
    To provide the needed care to our veterans, we rely heavily 
on our partnerships, and those partnerships include our DoD 
partners, our academic affiliations, as well as our community 
providers. For the VISN, we have 642 provider agreements, which 
means we can refer directly to those providers. For 
Fayetteville, they have 98 active provider agreements.
    VISN 6 also remains on the cutting edge of telemedicine, 
and Fayetteville alone provides 11 percent of their care 
through telemedicine. So this is something that we will 
continue to grow. We will continue to strive so that veterans 
may receive their care in their home through what we call 
Connect. So VA Connect will allow us to provide those 
telemedicine services to our veterans in their home or in their 
rural communities.
    Through all of these efforts, the VISN is currently, for a 
new patient appointment, at 12.8 days. Fayetteville, by having 
the opportunity to open our health care center and add the 
additional space and staff, has gone from 20.5 days for a new 
patient appointment a year ago to 9.3 days, and this is the 
best in the VISN. So Fayetteville is doing a very, very nice 
job of decreasing their time by adding staff and space.
    We were the first network to participate in what is called 
a market analysis. The market analysis was conducted by a 
third-party contractor. This third-party contractor looked at 
Fayetteville/Durham as one market, which is how can we take 
both of these facilities and expand our services in the 
community, as well as with our DoD partners, so that we can 
provide the needed care to this growing population?
    Our first expansion will be with Womack. We are currently 
doing surgeries. Our VA staff actually go to the Womack Medical 
Center and do surgery at that site. So that is just one leg of 
our partnership.
    Our next leg is also to work with our community partners to 
have a stronger partnership and bring services closer to our 
veterans.
    I have had the opportunity to brief our delegates on the 
market analysis, and as we move forward with these initiatives 
I plan on working very closely with both of these gentlemen and 
others so that we can have the needed services where the 
veterans live.
    I would also like to take a moment to introduce our new 
incoming medical center Director, Mr. James Laterza.
    James, if you would stand?
    [Applause.]
    Ms. Seekins. James is here with his wife, Christie, who is 
also a veteran. James served 32 years in the Army as a colonel 
at Landstuhl. He was also a former commander here at the Womack 
Medical Center in Fayetteville. So the VISN 6 leadership team 
is excited to get Mr. Laterza on board, and I will tell you he 
has been doing his pre-work and already working with us, but 
his first official day is April 2nd. So we are very pleased to 
have him join our team.
    I want to thank you for this opportunity for us to share 
with you the magnificent work that has been going on in VISN 6 
and hearing from our panel the work that has yet to happen. So, 
thank you again today for allowing us to be here.

    [The prepared statement of Deanne M. Seekins appears in the 
Appendix]

    The Chairman. Thank you all. I appreciate everyone's 
testimony.
    I will now just yield 5 minutes, and we may have a second 
round if the panel wishes to do that.
    Mr. Goodwin, we need to repair your good credit. I had 
cancer surgery the 31st of July this past year, and by the 15th 
of August all the bills were paid in the private sector, and 
here you are going on two years with your credit destroyed. We 
can do better, and we have to do better. This is not isolated. 
I can tell you that I have seen the very same thing in my own 
district.
    I am going to talk at the 30,000-foot level for just a 
minute and sort of give you all an idea about the direction 
that we are trying to take at the Veterans' Committee and the 
Veterans Department, the VA health care.
    The VA is made up of three components. One is disability 
claims, two is VA health care, and three is cemeteries. When I 
got to Congress in 2009, when I was first on the Committee, we 
spent $93.5 billion on all of those three services.
    As you all know, in 2011 we passed a bill called the Budget 
Control Act, which created the sequester. But during that time 
when the military lost a considerable amount of their funding, 
the VA funding went from $93.5 billion to the President's 
request this year of $198 billion. It has doubled during that 
time. So we as a country have stepped up.
    Now, I think a lot of the problems have been in 
administration and bureaucracy, as Ms. Verardo mentioned, 
things that are easily solved with just common sense. But this 
country spends more on its veterans than any country in the 
world; as a matter of fact, in all of the countries in the 
world put together. And for that, I think I am proud that the 
American people have never, ever busted me for supporting our 
Nation's veterans. I wanted to say that to start with.
    The VA has gone from 250,000 employees when I first got 
there, and they are now authorized for over 370,000. VA staff 
is now larger than the U.S. Navy. So we have got to do better. 
Just getting bigger doesn't make you better.
    Our vision in the Committee is this, and I know Dr. Dunn 
certainly shares this vision, is I really don't care where you 
get the care; as a veteran, I want you to get the absolute best 
care that this country can give you. I provided that care for 
patients for our local VA at home, and what we want to do is 
have these provider agreements that she mentioned so that a 
veteran can go and get the care, the quickest and the best care 
they can get. If the VA can provide it, great. If that is where 
the veteran wants to go, great. That is what our Choice bill is 
trying to do, is to allow the veteran to have more access.
    She mentioned something extremely important, that our 
country is changing, the demographics of the country are 
changing, and that is one of the reasons why I want the asset 
review done, because what she mentioned is look how much growth 
there is in this area of North Carolina and Virginia, whereas 
the Northeast is actually shrinking. What we want is a nimble 
VA, and I think there is no question in my mind from watching 
health care over the 40 years, more than 40 years that I have 
been a physician, is that we have gone from inpatient care to 
outpatient care, and the VA is making that change. There are 
over 800 outpatient clinics in the VA around the country.
    I was in Medford, Oregon not too long ago. The Congressman 
there, Greg Walden, his congressional district has more square 
miles than the state of Tennessee does. So that is a different 
issue. You have to go across mountain chains to get there. So 
you have to have a choice system where veterans can go outside 
there if they choose to do so. In a more urban--even though 
this may not seem urban, this is compared to that part of 
Oregon. Even though this is more urban and growing, we need to 
provide more services here, not less.
    So the VA needs to be more nimble, and by doing leases with 
these CBOCs, you can do that. In 20 years of health care 
changes, you can move away. I will promise you that 20 years 
from now, health care is going to look much different than it 
does today. And I will tell you this, an amazing statistic to 
me, hospitalizations maximized in America in 1981. We now have 
a 40 percent growth in population, and yet in-hospital care is 
down 10 percent. The reason for that is all the advances in 
technology that we have had. Look, my cancer surgery, I had 
never had an operation in my life, and I have had two major 
surgeries in the last 18 months. I have done thousands of 
operations. I got on the cutting end this time, the knife end. 
I spent less than 48 hours in the hospital for both of them, 
which is unheard of, and that is why we have to change the 
model, and we are going to do that.
    The other thing I want to bring up before my time expires, 
incredibly important to do what we are working on now, is this 
transformation to a new electronic health record. We have a 
system in the whole country, not just the VA, where one system 
can't speak to another, and we spend millions of dollars, and 
these two systems can't communicate to each other.
    So what we are doing now, I talked to a physician in 
Seattle, Washington that had acquired some medical practices, 
and they had 11 different health record systems in the same 
practice. So what we are trying to do is transform the VA from 
the system they have, which was cutting-edge many years ago. 
They have 130 different health record systems in the VA now. 
They are siloed in each medical center. With the new system--
and please, you veterans, be patient, because I put in an 
electronic health record system before. It is very difficult to 
do. But when we transform that, the goal is to get to the point 
where a veteran can leave DoD and seamlessly go to the VA and 
their records will be transferred.
    I am out in private practice. I have to have a Cloud-based 
system where that information goes from VA to the Cloud and 
then to me, and then I can send it back seamlessly to the VA. 
Until we get that kind of system, you are going to have these 
foul-ups that Sergeant Goodwin was talking about.
    Lastly, before I turn it over to Dr. Dunn, prompt payment. 
Medicare pays 95 percent of claims in less than 30 days, pays 
claims in less than 30 days. The VA is way out past that, and 
only about 60 percent of their claims are adjudicated in that 
same time.
    What we have to do to keep providers in the system--
Sergeant Goodwin, the very fine doctors that you saw are going 
to get out of the system if you don't pay them, and the EMS 
people can't operate an ambulance if they can't buy gasoline to 
go in the ambulance.
    So that is part of the new electronic health system so that 
that system will work better, and be patient, because it is a 
huge undertaking and a very expensive one.
    I have done something I never do, which is go over my own 
time. I usually gavel myself down, and I yield to Dr. Dunn. 
Sorry.
    Mr. Dunn. No, no. Thank you very much.
    He is quite right. He is very careful with the time, and I 
owe him a whole bunch of time.
    Thank you very much, Mr. Chairman.
    Ms. Verardo, let me say thank you for your testimony. I 
read it on the flight down, and I was grieving for you. Stories 
like yours are the ones that cause us to volunteer to be on the 
Veterans' Committee to try to tackle these problems, and let me 
offer you my apology for a very embarrassed United States 
Government and VA system for your travails.
    I want to get you on record as agreeing with me on 
something, I hope. Do you believe that specialty medical needs 
such as prosthetic care or transplant care are essential to 
include in the future legislation for veterans seeking care 
outside the VA?
    Ms. Verardo. I do, sir, yes.
    Mr. Dunn. Thank you.
    Mr. Catoe, what are your thoughts on making these specialty 
needs a priority in the future to the Choice system? Do you 
think this would be an improvement for veterans?
    Mr. Catoe. Yes, I think so. I actually used to work for a 
DME company. I was the Vice President of Reimbursement for a 
national company several years ago and I am quite familiar 
with--
    Mr. Dunn. Was that during the Choice program time?
    Mr. Catoe. No, sir, it is before that.
    Mr. Dunn. I will tell you, my practice was in the Choice 
program. Our experience was very, very similar in terms of the 
payments.
    Let me turn my next question to Ms. Seekins. I appreciate 
the opportunity to hear from the regional VISNs and what the 
local problems are. Clearly, Mr. Goodwin has indicated great 
satisfaction with the medical care that he received at the 
Fayetteville Veterans Administration hospital, specifically 
singling out Dr. Azad, and I hope you will recognize Dr. Azad 
for that. His experience does, however, underline that the 
payment system is way behind. In my own experience, the average 
payment reimbursement to my practice averaged well over 120 
days from the VA. Can you address that?
    Ms. Seekins. Yes. Thank you for that question. First, I 
want to say to Mr. Goodwin that I followed up as soon as I was 
aware of your case, and I believe that your payment is being 
made.
    Mr. Dunn. Now we just have to fix his credit.
    Ms. Seekins. Yes, and they are working on that as well, a 
credit letter and getting that taken care of. I apologize for 
that.
    I have Mr. Enderle here, who is our expert with VA 
regarding payment, so I am going to defer the question to Mr. 
Enderle.
    Mr. Dunn. Can you tell us what you are going to do to 
remedy this situation? And you are going to give me a level of 
confidence in the answer?
    Mr. Enderle. Yes, sir, I hope so.
    Mr. Dunn. And all in about a minute or so, all right?
    [Laughter.]
    Mr. Enderle. Thank you, and good morning. This is a great 
opportunity to be here to talk to you today. I also want to 
apologize to Mr. Goodwin for the difficulties he has been 
dealing with with his claim's payment.
    The VA realizes that many community providers have 
significant challenges with VA payment. Of course, we want to 
rectify that situation. Unlike Medicare and unlike Tricare, and 
even the TMTA program, unfortunately we have challenges that we 
need to overcome, one of those being--
    Mr. Dunn. We know you have challenges. We want to hear how 
you are going to fix it.
    Mr. Enderle. Yes, sir. How we are going to fix it is we are 
dedicating additional resources to address the claims 
processing time limits. We recently are sending additional 
claims to a staffing contract that is supporting us in 
processing claims. We expect that over the next--by the end of 
September, our claims backlogs will be addressed and resolved.
    To address the Choice claims, we are working with third-
party administrators to address their timeliness with the 
claim's payments, in addition to the waiting times with the 
call center for providers.
    Mr. Dunn. Because we are on the clock here, can you give me 
a sense of when you think this is all going to be made just 
right so the VA acts like Medicare in compensation times?
    Mr. Enderle. As soon as the VA has some relief with 
legislative changes.
    Mr. Dunn. We need that offline, because legislative 
language takes a long time to talk about, but we need it. If 
you think the legislative changes will fix that, I think I can 
guarantee you that the Committee would be very interested in 
hearing what those proposals are, real specifically how we are 
in the way, because we don't think we are in the way.
    Mr. Enderle. Currently, the VA has to pre-authorize care 
for veterans who are seen in the community. Because of that 
authorization process, we subsequently then process the claims 
that come in. We have to match those claims against those 
authorizations. So it is important that we ensure that veterans 
have authorizations in advance so that we can then seamlessly 
process those claims as they come electronically.
    Also recently--
    Mr. Dunn. So, our time is winding down. I am going to hope 
that the Chairman will get us through this and we will have a 
second round of questioning.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Dunn.
    Mr. Hudson, you are recognized.
    Mr. Hudson. Thank you, Mr. Chairman.
    As a follow-up to this line of questioning, I think this 
deserves a lot more time. Mr. Chairman, I actually have 
legislation I am talking with you about a number of times.
    My solution to this problem is if you are 50 percent or 
more service-connected, the VA will pay for anything whether it 
is connected with your injury or not. So if you are 50 percent 
or more service-connected, my legislation says you are 
automatically into us. That is one solution.
    Mr. Catoe, I was really interested in your testimony 
talking about the difficulties Atrium Health encounters when 
attempting to submit medical records to the VA and when you are 
seeking authorization for claims. There is a lot of difficulty 
dealing with the VA system, but you said in the private sector 
that you have these payer portals that process these much 
quicker.
    Could you maybe talk through that, exactly how those payer 
portals work in the private sector and maybe give us some 
advice about how we might use those in the VA system?
    Mr. Catoe. I can certainly try. Some of the major payers 
that we deal with, you can imagine who they are, but the larger 
payers, commercial payers, they have what we call payer portals 
where they have a system that we can actually scan records into 
our scanners, electronically transmit those records directly to 
them so that they can then take that transmission and attach it 
to the claim when it arrives and marry the two up. It is a much 
quicker process, much more secure. Of course, it is all HIPAA-
compliant and all that, and it just makes it a much easier 
process. Plus, we don't have the issue with losing medical 
records through the mail, mailing them to the wrong location, 
or them ending up being lost at the payer, which used to happen 
quite frequently, just like it does with the VA today.
    Mr. Hudson. Makes a lot of sense. I can go on my iPhone 
with an app and order a pizza, it shows up at my door. I don't 
even have to go to the bank to deposit a check anymore; I take 
a photo of it. We ought to be able to do payer portals with the 
VA and get these records, so you don't have to worry about them 
getting lost in the mail and having to re-submit it, you said 
sometimes five times.
    Mr. Catoe. That is correct.
    Mr. Hudson. Absolutely.
    Ms. Seekins, I appreciate your time here today, and I want 
to thank you for the way you have communicated with our 
delegation. Before you arrived, I reached out to the VISN 
several times and asked for briefings on some of the concerns, 
some that were highlighted here today. But when you first came 
into this position, you reached out to us and asked us to meet 
with you in open dialogue, and I really appreciate that 
approach. I think that is really important.
    I know of several companies right here in North Carolina 
that would be both willing and able to set up a payer portal 
type of system that could streamline this issue for the VA. Can 
you shed some light on maybe the VA's efforts to modernize, and 
is there a hold up? Is there some resistance within the VA 
system to this type of idea?
    Ms. Seekins. Thank you, Congressman Hudson. Again, I have 
Mr. Enderle here. We at the VISN side and at the Medical Center 
side coordinate the clinical care, and then Mr. Enderle's shop 
actually handles all of the payments. So again, I am going to 
defer to Mr. Enderle.
    Mr. Enderle. Thank you. As was explained, the medical 
record documentation and being able to transfer to the payer is 
complicated, and typically providers have to send that paper 
via the mail. It comes through the mailroom, goes to the 
medical records, and it is subsequently scanned.
    Mr. Hudson. Why can't we go to the payer portal? Do you not 
have the authority to do it? Is it someone higher up than you 
resistant to the change? What is the hold up?
    Mr. Enderle. Actually, we are taking steps to make sure 
that we are able to implement a process where those medical 
records can be submitted electronically. We currently have 
rolled out what we call the referral document tool. It is an 
online system where scanned electronic versions of medical 
records can be submitted to us electronically. We also have a 
tool called--
    Mr. Hudson. When you say rolled that out, what do you mean?
    Mr. Enderle. It is actually operational now.
    Mr. Hudson. So vendors like Atrium Health, are they now 
using it?
    Mr. Enderle. Some vendors are using it. However, we are 
working with the vendors through provider education to share 
the process with them so that they can begin using this tool.
    Mr. Hudson. It sounds like we have a communications problem 
between vendors and--
    Mr. Enderle. It has been available for the last probably 60 
days. We are still trying to educate providers on that tool and 
how to utilize it.
    In addition to that tool, we also have what they call 
Virtual Probe. It is a mechanism where we can exchange 
electronic information via email. It is also encrypted. So we 
can reach out to providers and ask them for their clinical 
documentation. Once we receive it, then we can load it up into 
the medical record at the VA.
    There is another system being put into place where probably 
over the next three months we will actually be able to accept 
clinical documents electronically to a contractor where they 
will submit paper documents to the contractor if they don't 
have the ability to be able to transfer electronically. We will 
be able to scan those clinical documents and then subsequently 
turn them into electronic documents, and then release them to 
the payment centers to process claims against them.
    So we are active in trying to resolve that issue, which we 
recognize is a problem.
    Mr. Hudson. I appreciate that.
    Mr. Chairman, I am over time, but this is breaking news. I 
hope maybe we can delve into this a little more and see how 
this is being applied.
    The Chairman. We will, and it is a system-wide problem. The 
VA doesn't need to reinvent the wheel. The systems are out 
there now, but the Secretary is very well aware of it, and it 
is one of the things that he has committed to get done. This is 
something if we don't do, we are going to have good providers 
peel off and not see our veterans. We don't want that.
    Mr. Pittenger, you are recognized.
    Mr. Pittenger. Thank you, Mr. Chairman.
    Again, I thank each of you all.
    Ms. Verardo, as you may be aware, this past fall the VA 
published a rule that restricted the ability for those 
requiring prosthetic limbs to seek access to the treatment 
outside of the VA. We have a bill that I am a co-sponsor of, 
and I think Mr. Hudson is too, the Bill of Rights for Injured 
and Amputee Veterans. What impact would that have upon you in 
terms of this new rule that is being imposed by the VA 
restricting the access?
    Ms. Verardo. Sir, our current situation with the VA to 
obtain any type of prosthetic device is archaic, at best. It 
goes through many channels of both approval, which I understand 
must happen when it is over $3,000, and it has to go through a 
secondary approval process, of course. But most recently, given 
my profile, I decided to go through my husband's most recent 
wheelchair issue kind of as a Jane Doe to see what it was 
really like, and it was horrifying. It took 18 days--this was 
recently, within the last couple of months--18 days for it to 
go just from my case management in PCP to the vendor. Had I had 
the opportunity to simply call the vendor and say, hey, this 
chair is broken, can you guys come on out, the vendor was 
incredibly responsive. They were at my house within 12 hours.
    So meanwhile I have three very small children, and I have a 
husband who is recovering from surgery. I had to basically 
stand backwards to push him while holding our children so that 
I could get him out of our house.
    The amputee clinic at VA also will withhold payment. Right 
now they have withheld payment to our vendor. We use hanger 
prosthetics because Mike is still in surgical recovery right 
now, so he is not weight-bearing, and they won't pay the vendor 
for this prosthetic until he puts it on, which is in direct 
defiance of his surgeon's orders to not weight bear.
    So we are very concerned about having a more streamlined 
process right now, integrating community care, but integrating 
it directly with the veteran, specifically with the caregiver, 
because we don't have that option to go direct to vendor right 
now for repair or authorization. We have to go through several 
channels within VA, including proving that the servicemember 
still requires some of these devices.
    Mr. Pittenger. Ms. Seekins, would you like to respond to 
that?
    Ms. Seekins. I will need to take this for the record to 
look into this case specifically. It is very hard for me to 
answer that question in a general form.
    I know that prosthetics is one of our foundational 
services, as you know. The Secretary has asked that we all 
focus on our foundational services, and within VISN 6, 
specifically at Fayetteville, we have made great progress in 
prosthetics with same-day services. I have had the opportunity 
to work with Ms. Verardo on specific cases, so we are making 
improvements.
    Are we where we want to be? No. We are looking at an 
orthotics lab. We are moving forward with many things so that 
we can provide those services to our veterans in a more timely 
manner. But as far as this case, I would need to look into that 
specifically.
    Mr. Pittenger. Again, Mr. Laterza, we are really grateful 
to have you here. Your leadership is extraordinarily important. 
The 200,000 servicemen and women who are entrusted to you, the 
dedicated professionals there to address their needs is really 
of great merit.
    Ms. Verardo, I would like for you to take the last minute 
or so to give any candid, thoughtful, concerned advice to Mr. 
Laterza on what you would hope to see and what you think could 
be done to better assist him to do what I know he wants to do.
    Ms. Verardo. Thank you. I am very encouraged by new 
leadership. Ms. Seekins has been truly a breath of fresh air, 
and she and I have a shared goal. Although we are a national 
organization, I want VISN 6 to be the best in the country, and 
I think we are going to work together to make that happen.
    As a caregiver to a catastrophically wounded veteran, 
empowering the caregivers is vital. I have had to place my 
power of attorney--I make my husband's medical decisions for 
the most part. I have had to place power of attorney on file 
with each individual different provider within VA. There is no 
consistency. Some providers will demand to still speak to my 
husband. I explain that it is very difficult for him to speak 
by phone or to understand some of the complex medical issues. 
So I think empowering the caregiver is vital and really working 
with the right community providers for actual choice and much 
quicker integration for cases like ours and the clients we 
represent at The Independence Fund. We represent thousands of 
those that are catastrophically disabled. We have awarded more 
than $50 million in direct support to these families.
    The catastrophically disabled, something can become--what 
is routine for another person is a life or death issue very 
quickly. So we would like that special classification and the 
formularies that reflect that. Thank you.
    Mr. Pittenger. Thank you very much.
    My time has expired.
    The Chairman. I think we will have enough time for, let's 
say, 3 minutes each, if there are any further questions.
    I do want to--I know that you have been at Landstuhl. I 
will be making my fourth trip there in about a month. For those 
of you all who are not familiar, the reason what Ms. Verardo is 
saying is so important is all of us have been to Afghanistan. I 
have been multiple times. During the Vietnam War, from the time 
you were injured until you got to a Level 3 center was 21 days. 
It took us that long.
    If you are injured on the battlefield today, and I have 
been all over Afghanistan, you can go from battlefield injury 
to reaching out to Bagram, then a regional surgical hospital, 
like in Jalalabad or wherever, to Landstuhl, to Walter Reed, 
and you can make that trip sometimes in less than 72 hours.
    If you see the flag, the American flag at Bagram, you have 
a 95 percent chance of surviving your injury. It is remarkable 
what we have done and the improvements that have been made in 
care. But it only begins there. We owe these veterans, like 
Mrs. Verardo, who is a true hero for me--I want to tell you 
that right now. What you have done to advocate, this is a 
lifetime commitment. This is not when we get you. This is a 
lifetime commitment we have, and I think your special category 
that you mentioned is something we can look at.
    There are some other things that just make common sense. If 
you are a veteran and you have lost a leg, you have lost a leg 
and you are not going to have that leg back. And if you need a 
wheelchair and it needs to be repaired, why don't we just have 
one there for you while your wheelchair is getting repaired? We 
should be able to fix that pretty easy, just here is another 
one to use, a loaner, just like when you take your car to get 
the oil changed sometimes you get a loaner. You do that. So 
there are some things we can definitely do that will alleviate 
these simple things that you bring up that the bureaucracy gets 
hung up on, just little common-sense things.
    I want to thank you specifically, because the first time I 
met you was at the White House, and then later at our caregiver 
roundtable.
    Folks, you have a real champion sitting in North Carolina 
here, I want to tell you that. She is not just for 
catastrophically wounded veterans but just veterans in general.
    Mr. Hudson?
    Dr. Dunn, I'm sorry.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    I want to focus on some of the niche areas of medical care. 
Sometimes that is internal medicine, like a specialized 
neurological problem or an immunological problem or a radiation 
treatment problem, or a surgical problem. Since I am a surgeon, 
I am going to stick to that area.
    Currently, any veteran who goes on the organ transplant 
list has to go to one of the 13 Veterans Affairs transplant 
centers. There is a rule that compels that on them. And none of 
those 13 centers performs all the different types of 
transplants. So we have veterans from Fayetteville who have to 
go to Michigan or Pittsburgh, or maybe farther than that, to 
get transplants.
    Now, we know that the veterans who go on the transplant 
waiting list, on the veterans list, wait on average 32 to 34 
percent longer than people on civilian lists. In fact, they 
have higher mortality rates because of that. They fail to get 
the transplant and die on the list, if you will.
    I am going to ask you about including transplants in the 
Choice program. Let the veterans go to a transplant center that 
is near them. Transplants are a unique form of surgery, very 
time dependent. So we know that the closer you are to the 
transplant center where you are being treated, the much better 
chance you get the transplant, but also it involves multiple 
trips to that transplant center. So if I have to go to Detroit 
again and again and again, both pre- and post-op, my chances of 
doing well are going downhill.
    So I am going to ask you about what do you think the 
chances are that we can include or remove this rule to compel 
them to stay in the transplant program in the VA and let them 
use the transplant centers, the Medicare-approved transplant 
centers that are near them. You have two right up the road 
here.
    Ms. Seekins. Yes. Thank you. This has been in place for 
many years, and you are correct, sometimes you have to go to 
Minneapolis, sometimes you have to go to Kentucky.
    Mr. Dunn. In the winter.
    [Laughter.]
    Ms. Seekins. They are known as Centers of Excellence for 
the transplants. We also have many of our hospitals that have 
strong affiliations such as Richmond and VCU, where the 
transplants are coordinated between the two.
    Dr. Bazemore is our physician on the panel, and I am going 
to ask Dr. Bazemore to comment on that, please.
    Dr. Bazemore. We do have these Centers of Excellence which 
perform transplants, and we had this discussion recently at a 
surgical summit in Durham, and the actual surgery office chair 
was there. The subject of transplantation came up, is it good 
for the VA to be in the transplant business, and it was a 
resounding yes. The reason being is that not only is it 
providing the care for our veterans, but also the accompanying 
services that support a transplant program in these Centers of 
Excellence also are being sharpened by having this service 
available.
    That being said--
    Mr. Dunn. We are constrained by the clock again. I want to 
talk to you afterwards, but I will point out for the audience 
in general that at least one of the Centers of Excellence does 
not meet the criteria to be reimbursed under Medicare for 
transplants. But we will talk about that after this because my 
time has expired.
    I yield back, Mr. Chair.
    The Chairman. Dr. Dunn mentioned that he was going to poke 
around. He is a neurologist, so be careful when--
    [Laughter.]
    The Chairman. Anyway, Mr. Hudson, you are recognized.
    Mr. Hudson. Mr. Chairman, we almost made it through the 
whole hearing without you saying something like that.
    [Laughter.]
    The Chairman. I couldn't help myself.
    [Laughter.]
    Mr. Hudson. I appreciate that, and I appreciate the focus 
Dr. Dunn has on transplants. I just dealt with a soldier, or a 
sailor that we were able to get to Duke University to get a 
transplant, and he was very close to not making it. He is now 
taking 57 pills a day just to not reject that. But it is a very 
tough surgery. But being close to your base of support and your 
family, your friends, is really important. So I think your work 
to keep folks near where their support system is is really 
critical, so thank you for that.
    This may be the last chance I get to talk, so let me just 
say also thank you to Dr. Larry Keen for hosting us here at the 
college, one of the best colleges in the country. Certainly, no 
college does more for our soldiers and our veterans. Thank you 
for all the great programs you have here.
    [Applause.]
    Mr. Hudson. I also want to introduce my staff, because I 
see a lot of folks here and I appreciate you all being here 
today. If anyone needs help with an issue with the VA, please 
see one of my rock star staff members here. I am going to 
introduce them.
    I will introduce the general, Chris Carter, but we know the 
sergeants do all the work.
    [Laughter.]
    Mr. Hudson. Chris Johnson, raise your hand. He works here 
in our Fayetteville office.
    George Lozier, raise your hand. He is the head of our case 
work operation across the district.
    [Applause.]
    Mr. Hudson. These two ladies, they make me look really good 
because they do a lot of great work on behalf of our veterans. 
If you are here today and you need assistance, please see one 
of them before you leave. Don't leave without doing that.
    Billy Costand, my district director; and then the bearded 
one behind the cameras, Chris Maples, also works here in the 
Fayetteville office and also in the Moore County office. Please 
see one of these folks if we can assist you in any way.
    I wanted to go to Ms. Verardo. Thank you so much for being 
here. I kind of choked up a little bit during your testimony, 
to be honest with you. When I first met you and Mike was in a 
wheelchair and could barely communicate, he was in tough shape. 
And then when you walked into my office, it is an emotional 
thing. But thank you for what you do and your advocacy. It is 
incredible.
    In your written testimony you talked a little bit about the 
flexibility that the catastrophically wounded have in terms of 
being able to choose your provider. Could you talk a little bit 
about that?
    Ms. Verardo. Absolutely. We think it is vital. We are 
insured, of course, through Medicare and Tricare for my 
husband. In those systems, he is deemed competent to choose his 
own provider, and then suddenly he is in the VA system and he 
is deemed incompetent to choose his provider. These are 
veterans, active military, that we are trusting to make 
tremendous decisions for national security purposes, and then 
we are telling them as soon as they enter the VA system that we 
deem them incompetent to even see who they can go to, the 
doctor of their choice.
    We would like to see major reform around that certainly, 
but a special category and designation for catastrophically 
wounded so that in terms of wait times, priority lists--the VA, 
of course, has priority lists and systems that we don't feel--
and I can tell you personally for me, they are not utilized 
properly. We would like to see real change around that.
    Mr. Hudson. Great. I appreciate that.
    Mr. Chairman, I believe I am out of time again, so thank 
you.
    The Chairman. Thank you.
    Mr. Pittenger?
    Mr. Pittenger. Thank you, Mr. Chairman.
    I would like to also introduce Bob Becker. Bob is our 
expert who has dealt with these issues for the last 15 years, 
and we really appreciate his work.
    Tom Guthrie is with my team, as well as Jake Caldwell is 
here in the Fayetteville office, and he will be responsive to 
you.
    Mr. Chairman, you mentioned that there are around 350,000 
individuals who work with the VA around the country. In any 
organization you have an A team and a B team, a C team, various 
groups of people who respond in a different manner perhaps. 
Some are more responsive, more capable, than others.
    I would ask you this, Ms. Seekins. Does the Director, Mr. 
Shulkin, Mr. Laterza, do they have the adequate authority to 
keep the right people, to promote the right people, to fire the 
right people, to make sure that we have the best folks? There 
have been so many GAO reports, 60 Minutes, so much that has 
been done to characterize, maybe good and bad, the VA and the 
quality of the care and the quality of the people in VA. That 
is really the bottom line to our veterans. Have we done enough 
legislatively to enable Mr. Laterza to be the effective leader 
that he needs to be?
    Ms. Seekins. Thank you for that question. And, yes, the new 
legislation, the accountability bill, has given us much more 
authority. I have not worked with Mr. Laterza yet as a senior 
leader to senior leader, but I have no doubt that he is going 
to be a person who holds his staff accountable.
    Mr. Pittenger. I wouldn't question him, his ability, but 
the appeals process could go on for years sometimes. Have we 
streamlined it enough? Have we given it enough teeth for him to 
do what he needs to be able to do? He is extremely capable.
    Ms. Seekins. Yes. There is only one loophole in the 
accountability bill that I have found challenging, and that is 
I can hold my staff, I can hold leaders accountable, but if 
they file a whistleblower, then any action against them goes on 
hold until that case is resolved. So I cannot remove them. It 
goes on hold.
    Mr. Pittenger. Thank you very much.
    I yield back.
    The Chairman. I thank you for yielding, and I appreciate 
very much everyone being here. To both the Carolina 
congressmen, thank you very much for inviting us down, and 
thank all of you all. My goodness, I didn't expect a room full 
of people. I thank the veteran service organizations who are 
here. It is great work you guys do and gals do advocating for 
veterans. You do an incredible job. We just finished five 
hearings listening to all the veteran service organizations in 
the country just in the last week.
    Does anyone have any closing comments they would like to 
make?
    Mr. Dunn. I would just say thank you to both Robert and to 
Rich, and to the college president, and to our panel.
    Mr. Hudson. I would just like to thank the panel for being 
here and giving your testimony. It is very important that we 
continue to get this on the record so that we understand. There 
has been a lot of work done, but there is a lot of work left to 
do, and we have a lot of challenges we continue to face, and it 
is important that we not only understand the challenges but 
understand how to fix them and where do we need to go to make 
this right and get the best care for our veterans that we can 
possibly get. I think everyone in this room agrees with that. 
That is our end goal.
    I want to thank the Chairman again for bringing the 
Committee here. I go to Washington every week we are in session 
and take your interests and try to represent you the best I 
can. In this case, I get to bring Washington to you and let 
your voice be heard in that way, too. So I appreciate that 
opportunity.
    The Chairman. Thank you.
    Mr. Pittenger. Mr. Chairman, I would like to say thank you 
as well. This means so much to the veterans. And, Richard, the 
same to you.
    I would say to those of you in a position to lead, I 
believe your hearts are in the right place. It is a big 
bureaucracy. We need to streamline it down so that it takes 
care of that individual person. You don't walk over people to 
affect the world. It is one person at a time. So, thank you 
very much.
    The Chairman. Thank you all.
    I want to give a shout out to my team. I would like for 
them to stand up. They are a part of my staff in Washington, 
D.C. on the Veterans' Affairs Committee.
    Alex Larch. Alex has been with me since back at day 1 I 
have been in Congress.
    Alex?
    And Samantha Gonzales, and Christine Hill. Christine is a--
we were driving down the 405 in Los Angeles rather briskly, and 
I said, ``Christine, what did you do in the military, in the 
Air Force?'' She said, ``I was a B-1 bomber pilot.''
    [Laughter.]
    The Chairman. And I said, ``Well, maybe we can slow it down 
a little bit.''
    [Laughter.]
    The Chairman. Anyway, thank you all. They have done a great 
job of putting all this together.
    [Applause.]
    The Chairman. I think I can speak for all of us. Truly, you 
don't know what you are going to do with your life when you 
finally grow up, practice medicine for 31 years. But it is a 
true privilege to serve our Nation's veterans.
    I had someone text me today about what an awful job we are 
doing in Washington, and I said, you know, we are doing some 
things that I probably don't agree with, but we are doing some 
things right. And the old statement that freedom isn't free is 
correct. I think I speak for every one of us up here.
    There are a couple of things I never apologize for spending 
money on, and we did it yesterday. Number one, if you are a 
warfighter, I want you to have whatever you need to take care 
of yourself and carry out your mission, number one.
    [Applause.]
    The Chairman. I have been at the tip of the spear. I know 
what that is like.
    Number two, I want you to have, when you come home, whether 
you have been injured or not, I want this country to provide 
for you the things we promised you we would do in a timely 
fashion. That is our job here today. It will never be done. We 
will never get it all right.
    I am a category 8. I am blessed. I have great health 
insurance. That category means I make too much money to go to 
the VA. I wouldn't want to be in front of a disabled veteran. I 
have care outside the VA. I think many of us feel like that. I 
speak to veterans every day who feel like that.
    But I want to thank everybody. I know this community. I 
grew up in Clarksville, Tennessee, which was the home of the 
101st Airborne Division. They don't have necessarily good 
things to say about here--
    [Laughter.]
    The Chairman. But anyway, I will keep that to myself. What 
happens in Clarksville stays there.
    But seriously, I grew up in a community like this, and I 
know how important the military, the culture is for this part 
of North Carolina, and how deeply the people care about the 
active-duty military and veterans in Fayetteville and this 
whole region of the country. Thank you for that. That wasn't 
the case always. At the end of Vietnam, that was not the case.
    I want to thank you for how you treat our veterans today. 
It is very much appreciated by this old veteran, I can tell you 
that.
    If there are no further questions, I want to once again 
thank our witnesses for all you said here today, and all the 
audience members who have taken your morning to be here with 
us. It has been a great pleasure to be in North Carolina where 
I don't need a translator to understand everybody. In 
California that is not the case, or New York. And I look 
forward to taking back these things. I made a few notes, and so 
have my staff, and suggestions of little things that maybe we 
can get done right quickly.
    I ask unanimous consent that all Members have 5 legislative 
days to revise and extend their remarks, including extraneous 
material.
    Without objection, so ordered.
    The hearing is adjourned.

    [Whereupon, at 11:28 a.m., the Committee was adjourned.]

                           A P P E N D I X

                              ----------                              

                  Prepared Statement of David W. Catoe
    Good Morning. I want to thank this committee for the opportunity to 
speak on behalf of Atrium Health system, formerly known as Carolinas 
Healthcare System. Atrium Health has always had an outstanding 
relationship with our Veterans in all communities we serve and we 
consider it a privilege to provide medical care to them. In fact, our 
health system has been recognized numerous times for supporting 
military personnel and Veterans through awards such as the Secretary of 
Defense Freedom Award, the Secretary of Defense Patriot Award, and 
being a Top 10 Military Friendly Employer. As we work to further 
support our Military Veterans, I would like to take a few minutes to 
highlight some of the issues Atrium Health is working to overcome in 
coordinating claims administration with the VA programs.

    1. Medical Records - Atrium Health often submits hard copy medical 
records multiple times to the VA for the same patient encounter because 
the VA is unable to locate and match up the records with the claims. 
This not only places a burden on the hospitals administratively, it 
also presents potential HIPAA/Privacy concerns since the VA appears to 
be unable to account for all the medical records that it has received 
from Atrium Health. Since VA will not pay a claim without the medical 
records - hospitals have no option but to continue sending records when 
requested time after time again. Our other commercial payers have payer 
portals through which we can upload medical records and other required 
documents directly to the payer for attachment to the claim - avoiding 
the printing and mailing of sensitive medical record information. VA 
should implement a HIPAA-compliant system for the electronic transfer 
of medical records and other documents needed for payment, similar to 
other payers who adjudicate claims.

    2. Authorizations - When Veterans present for medical care at 
Atrium Health, we treat them as our first priority - regardless of the 
administrative workings going on in the background. Most Veterans don't 
know the authorization number when they present and we often must 
obtain the number after the fact. Because there is both a clinical and 
claims component in the authorization process, there are handoffs 
occurring which often leads to trouble during claims administration. 
For example, VA faxes authorizations to a fax number in Clinical Case 
Management (CCM) at our hospital. This can be problematic to ensure 
that number also appears on the claim form days or weeks later. VA 
Choice often cannot provide us the authorization number when we call 
for it. Without this authorization, the claim will not be paid. It 
would be much more efficient and convenient for everyone if the VA 
could establish a portal so that authorizations could be pulled by the 
provider electronically and added to the claim as needed. This would 
eliminate unnecessary calls to the VA for the authorization number and 
improve the service provided to the Veteran.

    3. Excessive Hold Times - Atrium Health claims specialists 
experience excessive hold times when calling into the claims center to 
check on the status of claims. It is not uncommon to be on hold from 30 
minutes to three hours before reaching a VA or VA Choice claims 
representative. For VA Choice claims, we are only allowed to ask about 
three claims at a time before having to call back and go through the 
entire waiting process again to follow-up on additional claims. This is 
extremely problematic when we have thousands of outstanding claims with 
the VA and VA Choice at any point in time. We have also had to leave 
phone messages and emails with provider relations in the past since we 
could not contact a live person - but rarely do we ever receive a 
reply. The claims specialists at Atrium Health who work VA claims are 
often frustrated and demoralized due to the stress encountered as their 
productivity is hard to achieve when spending so much time waiting for 
assistance. More VA claims representatives are needed to handle the 
volume of calls received to avoid these excessive wait times for 
assistance.

    4. Education - VA needs to provide better education to the 
providers as well as the Veterans in explaining the different programs 
available for their care and the requirements for each program. 
Currently, these programs are very confusing to even an experienced VA 
claims specialist. I cannot imagine the confusion that many Veterans 
experience in trying to coordinate their care with VA. For example, 
many Veterans believe VA acts like an insurance policy when it in fact 
does not. An excellent example is the Other Health Insurance (OHI) 
amended regulation dated January 9th, 2018 wherein VA advised that 
providers should bill any available health insurance before VA and VA 
would be secondary to OHI for emergency services. However, VA is an 
entitlement and not an insurance program, thus they do not pay 
deductibles, co-insurance, or co-payments incurred by billing the OHI. 
Veterans still believe the hospital has the option to bill VA over OHI 
and we are at fault when the Veteran has a $1,000 plus deductible to 
meet - stating we should have billed VA first. The more communication 
and awareness there is on how these various programs work, the less 
confusion and more efficient processes we can have in place to serve 
our Veterans.

    Again, thank you for allowing me the privilege to discuss some of 
the opportunities our health system believes can improve our Veterans' 
experience as we provide medical care and the subsequent filing of 
claims with VA, VA Choice, and ChampVA. We are pleased to work with you 
and the VA to make the claims process more streamlined, efficient and 
friendlier to our Veterans.

                                 
                  Prepared Statement of Sarah Verardo
    Dear Chairman Roe, Representative Walz, and Members of the 
Committee, thank you very much for inviting me, as Executive Director 
of The Independence Fund, to testify before your Committee here today. 
I am Sarah Verardo, Executive Director of The Independence Fund, 
headquartered here in North Carolina, in Charlotte. I also wish to give 
special thanks to Representative Hudson of North Carolina for 
recommending The Independence Fund testify today in this field hearing. 
Representative Hudson has been an amazing friend to The Independence 
Fund, and the strongest of champions for Veterans here in North 
Carolina.
    Only 10 years old, we were founded in 2007 with the very specific 
purpose of assisting the most catastrophically wounded veterans from 
the Iraq and Afghanistan conflicts with adaptive mobility devices, and 
returning to them, at least in part, their independence. Since those 
humble beginnings, The Independence Fund's grown to also provide 
assistance for the caregivers of the catastrophically wounded and 
disabled, assistance to adaptive athletes and teams, wellness programs 
to combat the scourge of veteran suicide and post-traumatic stress 
disorder, veteran service programs to navigate the overly complex VA 
health care and benefit systems, advocacy programs to change the laws 
and regulations that unnecessarily limit veterans access to their 
earned benefits, and our newest program, Heroes at Home, which will 
assist the children of the catastrophically wounded and disabled.
    To date, The Independence Fund's provided more than $50 million in 
assistance to the catastrophically wounded and disabled and their 
Caregivers. This includes more than 2,200 motorized cross-country 
wheelchairs, 1,500 adaptive bicycles, and more than 150 Caregiver 
support retreats.

The Problem: An Unresponsive VA Health Care System

    But throughout those last 10 years, we've repeatedly found our best 
efforts hamstrung by a VA health care system that systematically and 
repeatedly fails to serve the very Veterans it was established to 
assist. While the medical care given by the individual medical 
providers is usually superb, that care is far too difficult to access 
and we find the medical care providers repeatedly thwarted by a medical 
administration bureaucracy seemingly more intent on preventing fraud 
and cutting costs than in optimizing care delivery for Veterans.

The Promises of Health Care Choice

    Mr. Chairman, The Independence Fund was heartened by the 
President's campaign promises to finally allow Veterans to be the 
masters of their own health care choices. Many of our clients are 
medically retired from the military due to their catastrophic wounds, 
and as such receive Tricare health care benefits. They can choose their 
health care providers, both at military treatment facilities and 
outside the Department of Defense. Similarly, many of these 
catastrophically wounded are eligible for Medicare, where they can 
choose pretty much any health care provider they want that participates 
in the Medicare program. Finally, the Caregivers under CHAMPVA are 
given wide latitude to choose their health care providers within the 
CHAMPVA system. In all these systems, the federal government finds the 
individual patient fully competent to make their own health care 
choices.
    But for veteran within the VA health care system alone, none of 
those choices are available. The veteran is considered incompetent to 
make any of their own health care choices and must rely on the 
beneficence of the VA bureaucracy to make proper medical choices for 
them. This, despite the stacks of Inspector General reports that finds 
that same bureaucracy engaged in deception to hide unqualified doctors 
committing malpractice; that details how that same bureaucracy is 
unable to deliver mandated health care on anything approaching a 
medically indicated schedule; and reveals a repeated unwillingness of 
that bureaucracy to critically examine its own practices or procedures, 
nor to explore the root causes of its multiple failures.
    This year, this Session of Congress, is the time to deliver on the 
President's campaign promise and deliver true and real VA health care 
choice. All parties involved in this debate understand the current VA 
Choice program is a stop gap measure until a consolidated, robust, 
system wide network of community care is provided to Veterans. While we 
supported the compromise proposal to the recent Omnibus Appropriations 
Act - which combined a version of consolidated, expanded access to non-
VA community care, and expansion of the Caregiver program, and a review 
process for the VA's capital assets - as of the writing of this 
testimony, we joined many other Veteran Service Organizations in our 
disappointment that the final deal was not agreed to for lack of 
universal agreement amongst all Congressional leaders.

Limiting Non-VA Care to Only That Prescribed by VA Doctors Will Not 
    Work

    Mr. Chairman, we cannot give up on passing real VA choice 
legislation. Veterans cannot wait any longer. While we appreciate the 
work the House and Senate Veterans Affairs Committees accomplished with 
their respective Committee passed bills, we are concerned both bills 
continue to rely on the VA to determine when and where Veterans can 
access non-VA care.
    Again, while the health care providers will usually seek optimal 
care for the Veteran, our experience is they are usually thwarted by 
the medical administration bureaucracy seemingly more intent on 
stopping perceived fraud by the very Veterans who defended this 
country, or to save money on the backs of the Veterans whose doctors 
believe they need this non-VA care.
    Let me give you an example. My husband, Mike Verardo, lost his left 
leg and much of his left arm in an IED explosion in Southern 
Afghanistan. His residual left leg suffers numerous skin infections 
that make the prolonged use of prosthetic sleeves dangerous and expose 
him to potential reinfection. Unfortunately, until recently the VA 
medical administrators refused to issue Mike more than two prosthetic 
sleeves every six months. VA has repeatedly cited this as policy to me 
and other amputee Caregivers, and our workaround included numerous 
direct appeal from Mike's own VA doctor to others within the same VA 
system and Congressional intervention. Mike's VA surgeon has prescribed 
a specialized prosthetic sleeves nine times, and each of those nine 
times, the VA's medical administrators denied those prescriptions. His 
surgeon was never consulted or notified that her prescription was 
rejected, it simply was never sent to us.
    This, Mr. Chairman, is why we cannot continue to rely on limiting 
access to non-VA care to that which is prescribed by a VA health care 
provider. Experience has shown the VA health care providers are 
powerless to prescribe non-VA care when VA medical administration 
bureaucrats have every incentive to deny that care and have every power 
to do so. Only when individual veterans have the authority to choose 
their own health care provider, whether that be within the VA or be 
non-VA care, will Veterans be able to access optimal care in a timely 
fashion.

Wheelchairs and Prosthetics

    This brings me to the specific issue of wheelchairs and 
prosthetics. Mike's and my personal experience, and the experience of 
our clients, is that the VA cannot deliver wheelchair and prosthetic 
repairs and replacements in a timely manner.
    For example, when Mike was retired from the military and we moved 
back to Rhode Island, his prosthetic leg was damaged, but we had to 
wait 57 days for a VA medical administrator to sign a form authorizing 
the repair of the prosthetic. Eventually, the prosthetic vendor grew 
disgusted with the VA and provided a new prosthetic without 
authorization, risking non- payment. In the meantime, I was forced to 
duct tape Mike's leg to keep it even somewhat operational. More 
recently when I requested a wheelchair repair or replacement from VA, I 
was told that they'd need to evaluate if Mike still had injuries that 
required wheelchair use. Please keep in mind that limb loss is 
permanent.
    The VA Inspector General released a report last week detailing 
similar problems with wheelchair and prosthetic repairs in VISN 7. The 
first remarkable item in this report is that the VA apparently has no 
standard for how long it should take to repair wheelchairs and 
scooters. Second, the VA IG found the average wait time was 99 days. 
Some of the Veterans researched in this study were bedridden for more 
than 100 days while their wheelchairs were being repaired.
    Lastly, the VA IG detailed the repair administrative process. That 
process seems incredibly complex and unnecessarily duplicative. A 
simple process review would likely be able to trim substantial time and 
steps from this process. The Independence Fund recently met with the 
Central Office Prosthetics and Wheelchairs Department, and we are 
hoping to enter some Memorandum of Understanding with the VA to help 
them improve those processes. We request your support with the VA to 
enter into such an agreement with us.
    But again, Mr. Chairman, we do not believe there are any 
circumstances where the VA will be able to adequately respond to 
Veterans' prosthetic and wheelchair repair and replacement needs. 
Having to wait until the point of failure for the VA to even initiate 
repair or replacement action and having no spares available for the 
Veteran to use in the interim, highlights a system unresponsive to the 
basic needs of disabled Veterans. Even the 30-day repair standard the 
VA IG arbitrarily applied in their report (since the VA does not have 
its own repair/replacement standard), is unacceptably long. Therefore, 
we recommend Veterans be allowed immediate access to non-VA care for 
the repair or replacement of prosthetics, wheelchairs, and scooters.

Standards of Care and Formularies for the Catastrophically Disabled

    There is, unfortunately, a broader issue at hand which we see with 
many of our catastrophically disabled clients, Mr. Chairman. For the 
catastrophically disabled, even minor delays in accessing medical care 
can quickly devolve into life threatening emergencies. What would be a 
minor inconvenience for a Veteran suffering from one or two isolated 
disabilities, can be a matter of life or death for a catastrophically 
disabled Veteran.
    Like the example with the prosthetic sleeves, most formularies and 
standards of care appear to be designed in isolation for that one 
specific malady and fail to consider the interaction of multiple 
traumatic wounds and injuries sustained by the catastrophically wounded 
and disabled. In such situations, the catastrophically disabled Veteran 
finds themselves unable to receive the care they need in time to 
prevent additional maladies from occurring which exacerbate the 
Veteran's illnesses and disabilities.
    The VA community care expansion legislation you recently 
negotiated, Mr. Chairman, to provide automatic access to non-VA care 
where VA facilities fail to meet established access standards, and to 
provide access at the discretion of the Secretary where VA facilities 
fail to meet VA established quality standards, may also be insufficient 
to protect the health of the catastrophically disabled. The medical 
needs of the catastrophically wounded and disabled are far different 
than those with non-catastrophic disabilities. Hence the special VA 
classification for the catastrophically disabled. But access and 
quality standards must also consider the special requirements of the 
catastrophically disabled.
    Therefore, Mr. Chairman, we recommend any future legislation to 
define when and where Veterans are eligible for non-VA care should 
establish separate, specific access and quality standards for the 
catastrophically disabled which will be applied, and under which 
catastrophically disabled Veterans can qualify for non-VA care, even if 
the standard access and quality standards are otherwise met. Similarly, 
we believe the VA should be directed to establish separate formularies 
specifically for the catastrophically disabled that consider the unique 
and complex nature of their disabilities.
    Thank you again, Mr. Chairman, for the opportunity to appear before 
this Committee today. I look forward to answering any questions you may 
have.

                                 
   Prepared Statement of Staff Sergeant (SSG) Retired Gary B. Goodwin
    Mr Chairman, House Veterans' Affairs Committee Members present, 
Congressman Richard Hudson, other Invitees and Guests. I am humbled 
that you have invited me to this field hearing today and welcome you 
all to the great city of Fayetteville, North Carolina. Our city motto 
is History, Heroes, and a Hometown Feeling and that can be seen 
anywhere you travel in Fayetteville. I am proud to call Fayetteville my 
home for the past 30 years. Fayetteville is the home of Fort Bragg 
where duty, sacrifice and love of our great country is on display 365 
days a year.
    Before I offer my testimony, I want to make clear to the Committee 
and all in attendance that any issue(s) I currently have with the 
Fayetteville VA Medical Center (FVAMC) are administrative in nature. I 
have been receiving 100% of my medical care thru the FVAMC since 1994 
(24 years) and am 100% satisfied with the EXCELLENT level of care 
provided to me. I often tell people not to believe all the negative 
press they hear about the VA in general. Why? If my experiences with 
the FVAMC are any indication of what the VA offers, I am hard pressed 
to believe every negative story in the media today. Is the VA system 
perfect? No. Show me any large scale medical system in the world that 
is!
    In that vein, I would like to offer my personal thanks and 
recognize my Primary Care Provider Dr Abul K. Azad, MD and his Staff 
Nurses Lillian Figueroa and Tracy Ford for all they have done for me. 
Time constraints do not allow me to also thank countless FVAMC Staff 
Members who have also offered me quality care and compassion. I am 
thankful for what they do for this Veteran!!
    The past four years have been medically challenging for me. Three 
major surgeries, two minor surgical procedures, numerous 
hospitalizations and countless ER/Urgent Care visits. This includes 
experiences with the FVAMC, Veterans' Choice and Non-VA Care.
    I was asked to speak to with the Committee regarding a specific 
issue that, as of today, has not been 100% resolved.
    I have encountered an issue with the VA that I have been unable to 
resolve on my own after repeated attempts to do so. Non-payment of Non-
VA medical expenses that have been approved by the VA for payment. I 
offer my testimony regarding this issue as I imagine I can not be the 
only Veteran this has happened to.
    On July 22, 2016 (Friday), I sought ER care at a Non-VA Facility 
for issues related to a recent thoracic/chest surgery. I followed the 
appropriate procedure(s) and notified the FVAMC of same the following 
Monday (July 25, 2017). After several inquiries, I finally received a 
letter from the FVAMC, dated January 13, 2017, stating this episode of 
care has been verified, claim approved by ``Salem'' and pending 
payment.
    I learned recently that the VA has finally began making payments to 
the ER providers now 24 months post dates of service. It remains 
unknown to me if the VA has communicated with the providers to advise 
of payment delays or specific reasons for payment delays. I have 
previously made repeated inquiries to the Fayetteville Non-VA Care 
Office and the Fayetteville VA Director's Office without success.
    I contacted the VA Office of the Inspector General (OIG) and 
received a response stating they do not investigate these matters. The 
OIG urged me to contact the VA Compliance and Business Integrity Office 
(CBI) regarding this matter and provided a name and e-mail address for 
contact. I sent an e-mail to the named CBI official seeking assistance. 
I have not received an acknowledgement or response to date.
    I contacted my Congressional Representative Mr. Hudson on November 
6, 2017 for assistance. Mr. Hudson's Deputy District Direct, Georgia 
Lozier, has been very helpful in seeking a resolution on my behalf.
    I have also been in contact with our local ABC television affiliate 
ABC 11 WTVD, in Raleigh. Their Trouble Shooter has been in contact with 
the VA on my behalf and is preparing a televised report about their 
efforts to assist.
    I have extensive documentation/names/dates to support my claimed 
inquiries.
    The ER providers have been contacting me with threats of lawsuit(s) 
or collections. I have provided each ER provider with a copy of the VA 
payment letter mentioned above. One provider has now attached a 
negative balance due to my credit report with Equian. This has resulted 
in my rejection for a home equity loan that was submitted to my 
mortgage company in November 2017. Additionally, my credit score has 
dropped from 820 to 670 as a result of non-payment by the VA.
    The EMS provider turned my account over to collections and posted a 
negative balance due to my credit report with Equian. This has resulted 
in significant damage to my ability to gain credit for home 
improvements, new household furniture and co-signing for my son on his 
recent new vehicle purchase. My 25 year old son's credit score is 780. 
How does my 25 year old son achieve a greater score than me?? I have 
preached to him over the years regarding the importance of financial 
responsibility as a good credit standing ``makes the world go around''.
    The EMS provider, Brunswick County EMS. is now attaching a 
garnishment to any tax refund I may receive from the State of North 
Carolina? I am attaching a copy of their letter to me dated 11/30/17 
for your review.
    I contacted each provider in January 2018 for status:

    Brunswick County EMS - Called provider and offered my private 
health insurance, United Healthcare (UHC), information for payment. 
Same was declined as provider will not bill insurance for services > 1 
year old. I submitted a manual claim to UHC for consideration and 
pending. UHC will likely not cover as claim filed > 1 year post date of 
service 7/22/16.
    Novant Health (ER) - Called and spoke to Financial Services 
Representative. Novant has written off my entire bill as uncollectable 
and the current balance due is $0.
    Carolina Health Specialists (ER MD) - Called and spoke to 
Representative, provided my private health insurance information. 
Provider will file claim with UHC.
    Delaney Radiologists PA (ER Radiology) - Called and spoke to 
representative, I paid $46 balance due out of pocket.
    On February 15, 2018, I received an update from Ms. Lozier and was 
advised that an un-named VA Representative providing her the following 
statement:

    ``Good morning Ms. Lozier, Our apologies for the delay in 
processing this claim. Our payment center had previously suspended the 
claim for Pending VA/Office General Counsel Millennium Health Care Act 
decision (Emergent care for a non-service connected condition) because 
the Veteran had other insurance and after clinical review it was deemed 
that it was unrelated to his service connected condition. The letter 
dated 1/23/17 was subsequently sent to the Veteran from the 
Fayetteville VAMC, our payment center office was not aware of the 
letter, nor was aware that the VAMC had authorized the emergent care as 
a result of complications to previous authorized surgery. However, the 
VAMC did not enter the authorization into their system until 2/7/18.
    The following claims, UB #600609 and HCFAs 2296422, 2306945, 
3539367 for providers Novant Health, Delaney Radiologist, and Strand 
Physician Specialists were processed immediately after authorization 
entry and were sent to payment on 2/9/18. The claims associated to the 
hospital are in batches pending release for payment. The ambulance 
claim will be processed by the VAMC Beneficiary Travel Office since the 
transport is authorized.
    We have reached out to the VAMC to share this example with them and 
we will make every effort to improve communication between the VAMC 
Fayetteville and our payment center office so this issue does not 
happen again.
    Again, we apologize for the delay in processing payment and the 
inconvenience caused to Mr. Goodwin. Please let us know if additional 
information is needed''.
    On March 3, 2018, I received written notification from the FVAMC 
that the ER, ER MD and ER Radiology services have been pain and in what 
amounts. There was no mention in the letter that the EMS provider has 
been paid and what, if any action(s), the FVAMC would take to assist me 
with removing the negative post to my credit report.
    On March 15, 2018, I e-mailed a local FVAMC Non-VA Care Supervisor 
about the pending payment to the EMS Provider and a conversation that I 
just had with member of the FVAMC Beneficiary Travel Office. I have 
redacted names and phone numbers due to privacy issues.
    ``Paragraph 2 from the February 15, 2018 update states the EMS bill 
to be paid by VAMC Beneficiary Travel Office. Correspondence I have 
received, from other sources regarding the EMS bill, indicated a person 
named ``X'' was the point of contact. So, I just called the FVAMC and 
asked to speak to ``X'' in the VAMC Beneficiary Travel Office. I then 
spoke to ``X''. He stated payment for EMS transport was ``sent to 
Texas'' and became somewhat frustrated when I asked for clarification. 
He could not or would not say if payment has been made or when?
    I asked for his Supervisor's contact information, called 
``Supervisor Y'' and left a message for callback regarding payment of 
the EMS bill from 7/22/2016 and assistance with removing the negative 
entry from my credit report.
    The FVAMC Non-VA Care Supervisor called me later in the afternoon 
and advised the authorization for payment of the EMS bill was approved 
and payment would be forthcoming from a VA Payment Center in Texas. She 
could not definitively say when payment would be made or what action 
the FVAMC would take to assist me with the removing the negative credit 
report posting.
    I have yet to receive a response from ``Supervisor Y''.
    As of today, and a full 24 months after my ER visit on 7/22/16, I 
remain hopeful that the EMS payment in question will be paid and the 
FVAMC will offer its full assistance in repairing the damage to my 
credit report. I will happily provide the Committee with any documents 
they require.
    Thank you, Mr. Chairman, the Committee and Mr. Hudson for all you 
do to support our nation's great Veterans.

                                 
                 Prepared Statement of CMSgt Daryl Cook
    Good morning Chairman Roe, Dr. Dunn, Congressman Hudson and Members 
of the Committee on Veterans' Affairs. It is truly a pleasure to be 
provided the opportunity to share my experiences as it relates to the 
Veterans Administration and more importantly share many positive 
experiences. I will also provide some issues within the program I feel 
are recommended areas of improvement. While I currently serve as the 
Installation Fire Chief assigned to the 145th Airlift Wing my testimony 
are my views and not those of the 145th Airlift Wing or the North 
Carolina National Guard.

Introduction

    As mentioned, I serve as the Installation Fire Chief to the 145th 
Airlift Wing in Charlotte where we mutually respond with Charlotte Fire 
Department to emergencies at Charlotte Douglas International Airport, 
the sixth busiest airport in the country. Additionally, our mission 
includes providing emergency services support for Stanly County 
Airport. I have 32 Drill Status Guardsmen and 24 North Carolina State 
Employees to assist in providing coverage to these locations.

Background

    With a varying number of personnel between military and civilians I 
have the opportunity to serve with many individuals who deal with the 
Veterans' Administration and typically information I receive is 
positive in nature. Close to 100% of my personnel have deployed so many 
have direct interaction with the VA prior to and after their 
deployment. Most of the information I provide is positive in nature but 
as with any program, improvement to the process and overall goal of 
providing the best care to our veterans can always get better.

Input from the Field

    MSgt Christopher Johnson is also assigned to the 145th Airlift Wing 
and when asked about his interaction and service with the VA, he had 
nothing but favorable comments about his experience: staff was very 
friendly/professional and informative with the services they provide; 
facilities utilized were clean and in good condition; was able to get 
referred to a nutritionist and eye doctor in a timely fashion and when 
he needed services from the Emergency Department in Charleston, SC he 
received prompt and excellent service.
    CMSgt (R) Pete Hazleton previously assigned to 145th Airlift Wing 
now assigned as a State Firefighter with the Air National Guard 
utilizes the VA's medication program and primary physician program with 
positive success. There are difficulties and concerns in scheduling 
appointments; it takes excessive time to get an appointment, may be 
months out, and the process for making the appointment and getting a 
referral is not an easy one. When directed to have lab work done it 
typically takes an extended period of time and many times orders are 
not there when you arrive to have the labs.
    MSgt (R) Donald Willis previously assigned t the 145th Airlift Wing 
now assigned as a State Assistant Fire Chief with the Air National 
Guard. In January of 2017, he contacted the Veteran's Administrator of 
Catawba County to ask questions about the VA benefits that came with 
retirement. He was informed by them that his finances made me 
ineligible for the VA medical care benefits.
    He retired from the NC Air National Guard on 10 Jun 2017. He went 
to the VA office in Charlotte in September 2017 to ask about applying 
for service related injuries. He filled out the paperwork and the VA 
representative made him an appointment with the VA clinic in Charlotte 
on 26 October 2017. He went to the appointment and his medical records 
were transferred to the VA. He started his paperwork for the service 
related disability. The VA clinic made his next appointment for one 
year later, 26 October 2018 at 1000 hours.
    He received a letter in the mail on 19 March 2018 from the VA 
advising him that his appointment for 26 October 2018 had been 
cancelled, and providing him some numbers to call and find out why. He 
called the 800 number given and spoke to a representative who looked up 
his appointment. The representative stated that his appointment was in 
fact cancelled. He asked her what the reason was for the cancellation. 
She checked the system and stated that it was probably because he made 
too much money. He did receive letters from the VA telling him they 
were looking into how much he made annually.

Conclusion

    In closing I want to thank you for the concern and the effort 
you've put forth in ensuring our veterans receive the best care 
available. I appreciate the House Veterans Affairs Committee being 
proactive and seeking out ways to better serve our nation's veterans. 
Additionally, I would like to thank those who have served before me, 
those I've had the opportunity to serve with, and those who will serve 
after me. It is truly an honor to serve this great nation. God Bless 
this committee and God Bless the United States of America.

                                 
              Prepared Statement of Deanne M. Seekins, MBA
    Good morning Chairman Roe, Ranking Member Walz and Members of the 
Committee. I appreciate the opportunity to discuss the Department of 
Veterans Affairs' (VA) Fayetteville VA Medical Center (VAMC) and the 
partnership with the community to provide quality and accessible 
healthcare. I am accompanied today by Dr. Mark Shelhorse, Veterans 
Integrated Service Network (VISN) 6 Chief Medical Officer and Interim 
Medical Center Director at the Fayetteville VA Medical Center, and 
Joseph Enderle, Choice Program Manager, Office of Community Care.

Introduction

    The Fayetteville VAMC is a Complexity Level 1C facility that 
consists of a 58-bed general medicine, surgery and mental health 
facility located in the North Carolina Sand Hills within 10 miles of 
Fort Bragg and Pope Air Field. The Medical Center also maintains a 69-
bed long-term care Community Living Center (CLC) to care for Veteran 
residents and adjacent to the Medical Center is the North Carolina 
State Veterans home, a 150-bed long-term nursing home facility. The 
Fayetteville VAMC serves 74,000 patients in 19 southeastern North 
Carolina counties, which is one of the largest catchment areas in VISN 
6. The Fayetteville VAMC operates two Health Care Centers: one in 
Fayetteville and one in Wilmington, along with community-based 
outpatient clinics (CBOC) in Brunswick, Goldsboro, Hamlet, 
Jacksonville, Robeson, and Sanford. The CBOCs provide Primary and 
Mental Health Care and offer Tele-health services for other 
specialties. Located offsite in Fayetteville, the healthcare system 
opened the first freestanding community Dialysis Center in the VA 
health system nationwide in 2011. This unit has the capacity to treat 
64 dialysis patients daily. In addition, Marine Corps Base Camp Lejeune 
and Seymour Johnson Air Force Base are located within the facility's 
catchment area.

Growth in North Carolina

    Overall, North Carolina's population has grown by 611,000 since 
2010, an increase of 6.4 percent. North Carolina is the fifth largest 
state for relocation. During this time frame, VISN 6 has led the Nation 
in Veteran population growth with a 118 percent increase, and this 
trend is expected to continue.
    While North Carolina boasts several universities with top-tier 
medical and nursing schools and allied health programs, not all North 
Carolina residents have ready access to urban or academic-affiliated 
health care. The surrounding communities are notably rural, especially 
those surrounding Fayetteville, NC. According to the North Carolina 
Department of Health and Human Services, between 70 and 80 of the 100 
counties in North Carolina are underserved in terms of primary care, 
mental health and/or dental resources. As of September 30, 2017, 42 
percent of those Veterans receiving services in North Carolina are 
deemed rural. In the Fayetteville catchment area 17 of 19 counties are 
considered rural.
    It is a challenge to provide healthcare in this environment because 
there often are not enough providers to meet the demand for care. To 
address this challenge, VISN 6 has fully embraced VA's modernization 
efforts and is actively focusing on providing exceptional foundational 
services while expanding partnerships with community and Department of 
Defense (DoD) health care systems to ensure world-class care to all 
Veterans, including those residing in rural areas. VISN 6 and the 
Fayetteville VAMC have focused heavily on addressing the access 
concerns related to the rural nature of the location and the population 
growth by making meaningful changes in both VA-provided services as 
well as those delivered in partnership with DoD and the community.

Improving Access within the Health Care System

    As has been the case across VA, improving access to care has been 
among Fayetteville's top priorities for several years, but the efforts 
have recently intensified resulting in considerable improvements. 
Specifically, 96 percent of time sensitive appointments have been 
completed on or before the patient indicated date. Fayetteville's 
leadership has been taking steps to improve access using a broad 
variety of strategies, including the following:

      Partnered with community providers, DoD facilities and 
other VA facilities to provide services;
      Built internal capacity and access by adding 420,000 new 
square feet of clinical space in the past 4 years with a corresponding 
increase of 841 new staff;
      Established a Patient Aligned Care Team working at Camp 
Lejeune;
      Expanded hours during the week using 10-hour shifts and 
implemented evening and weekend clinics as well as extended hours for 
diagnostic radiology;
      Increased efficiency by 25 percent in the Fayetteville 
Health Care Center primary care by redesigning the clinical area to 
accommodate 5 teams in the same space previously designated for 4 
teams;
      Utilized partnerships with other VAMCs to maximize the 
use of telehealth in the areas of primary care, mental health, and 
specialty care;
      Increased the use of registered nurse clinics and secure 
messaging to supplement face-to-face visits with providers;
      Implemented Clinical Practice Management guidelines to 
promote optimal resource use and maximize the clinical time available 
for staff to see Veterans;
      Expanded the number of academic affiliations and 
established a recent agreement with the School of Osteopathic Medicine 
at Campbell University; and
      Initiated construction projects to renovate operating 
rooms, inpatient units and the Community Living Center.

    In addition, Fayetteville is working to provide greater flexibility 
and alleviate bottlenecks that potentially impact access by maximizing 
its use of community care. Services available to Veterans through 
community providers include physical therapy, pain management, 
audiology, dermatology, optometry, neurology, obstetrics, cardiology, 
orthopedics, rheumatology, podiatry, primary care, sleep medicine, 
chiropractic services, and in-patient hospitalization.

Major DoD Sharing Agreements

    The VA Mid-Atlantic Health Care Network and the Fayetteville VAMC 
consider their partnerships with DoD to be a critical aspect of 
providing care to Veterans. Resource sharing agreements are in place 
with Womack Army Medical Center on Fort Bragg, the Naval Medical Center 
Camp Lejeune, and Seymour Johnson Air Force Base's 4th Medical Group.
    The agreement with Womack Army Medical Center provides access to 
many specialty services currently not available at the VAMC. 
Specifically, VA surgeons are using Womack's operating room suites 
during the VA Medical Center's operating room renovation project. In 
addition, the Fayetteville Rehabilitation Clinic, a Joint Incentive 
Fund initiative with the Womack Army Medical Center, opened in May 
2017, and provides physical medicine and rehabilitation services to 
both Veterans and active duty Servicemembers. The Naval Medical Center 
at Camp Lejeune provides Veterans with access to emergent and inpatient 
care while the Fayetteville VAMC provides care for active duty 
Servicemembers. Finally, the Seymour Johnson Air Force Base partnership 
provides opportunities to share services such as diagnostic x-ray, 
physical therapy, mental health, and anti-coagulation clinics.
    The Fayetteville VAMC is currently working with the Womack Army 
Medical Center to expand their current agreement to create a more 
robust and innovative partnership. A final agreement is expected during 
the 3rd quarter of fiscal year 2018.

Timeliness of Community Care Payments

    On January 3, 2018, VA announced a series of immediate actions to 
improve the timeliness of payments to community providers when VA has 
purchased community care. In addition, VA's contractors for the 
Veterans Choice Program, Health Net Federal Services and TriWest 
Healthcare Alliance, are committed to working with VA to improve the 
timeliness of payments to community providers and are working 
diligently with VA, VISNs and facilities to accomplish that goal.
    VA realizes that many community providers have challenges with the 
VA payment process, and VA wants to improve its service. Over the past 
2 months, VA has focused on the top 20 providers nationally with the 
highest dollar value of unpaid claims and created rapid response teams 
that are currently working with those providers to resolve those 
claims. In addition, VA is increasing the number of claims processed 
within 30 days of submission through use of additional contractor 
support. Through these efforts, the number of claims processed in the 
last 2 months has increased substantially, and we are well on our way 
to our goal of eliminating our claims backlog by September 2018.
    VA is aware that smaller providers play key roles in more rural 
communities in providing continuity of care for our Veterans. Because 
of their smaller size and the lower volume of care furnished, the total 
value of these providers' unpaid claims would also be less, but VA is 
working with facilities to identify smaller providers who are important 
providers of Veteran care and will also be working with them. Lastly, 
VA realizes that provider education about claims processing is 
important in assisting providers in submitting their bills accurately. 
VA has been providing education to the providers with the highest 
dollar value of unpaid claims as part of the outreach. We have seen the 
value of this outreach and will begin offering monthly training calls 
in April for the entire provider community. This will allow any 
provider to join in and learn about VA processes.

Conclusion

    The Fayetteville VAMC has made significant improvements to meet the 
needs of our Veterans. In order to sustain these efforts, we ask 
Congress' continued support of VA modernization by investing attention 
and financial resources into the following: streamlining leasing 
process, recruitment and retention incentives for hard-to-hire 
occupations and locations, and flexible funding models to improve the 
speed and efficiency in which medical centers need to respond to 
challenges. These are in addition to improving VA's community care 
authorities.
    It is critical that we continue to move forward with the current 
momentum and preserve the gains made thus far. Your continued support 
is essential to providing care for Veterans and their families.
    Mr. Chairman, this concludes my testimony. Thank you very much for 
your attention. My colleagues and I are prepared to answer any 
questions.

                                 [all]
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