Hello... Clarice

Rating Veterans Service Representative (RVSRs) are tasked with:

• Ensuring claim/appeal paperwork have been completed properly;

• Ensuring all Duty to Assist obligations have been satisfied;

• Reviewing evidence;

• Ordering examinations;

• Reviewing DBQs and IMOs; and

• Properly assigning evaluations and effective dates.

  • For a full list of responsibilities click HERE.

Just like VSRs, raters are assigned claims via the NWQ. Again, the goal is to process all assigned claims within 5 business days.

It is important to know that the NWQ is far beyond mere mortal understanding. Claims raters get could have been marked RFD the day prior or more than 3 months ago! The only thing that stands to reason is that claims marked as Priority DO seem to get to rating faster more often than not.

RATER NOTES:

• In the case of claims of Lou Gehrig's disease (ALS), which have an exceptionally high priority, those will receive a partial decision the same day VA gets the claim (assuming appropriate service can be verified and a diagnosis is of record). So if appropriate, service-connection at the 100% rate will be given in addition to various ancillary benefits; the rater will defer for a medical examination to determine the current severity of ALS residual condition(s). This usually results in grants of upper levels of Special Monthly Compensation (SMC) depending how progressed the condition is.

  • This is because the disease can progress VERY QUICKLY and delaying even a day can result in the Veteran passing away before a decision is made.

Trust no one - reviewing evidence

A good rater should trust no one and have faith only in the evidence of record!

An ironic thing about being a good rater is that good raters will spend most of their time... not actually rating. No, I do not mean they are farting around watching Netflix. I mean they are investing the time to make sure the claim has been properly developed and that the VAs duty to assist has been completed.

The VAST majority of claims that come before a rater are not fully ready for decision. Now to be fair to VSR's, this is not always their fault. Sometimes medical examiners overlook evidence, mess up a DBQ, or provide an insufficient medical opinion. But other times, rating will get claims with exams not ordered or medical records not obtained! At the absolute worst, sometimes claims will make it to rating after nearly a year and the claim paperwork will be invalid (paperwork not being signed)!

For every claimed condition, the rater should always review the evidence of record! While it seems obvious, we know this isn't always being done unfortunately... This review will fairly often result in finding that required exams/opinions were not ordered by the VSR.

Medical opinions

Raters are not medical professionals and CANNOT provide medical opinions, which is why VA requests them. Meaning, if you get a bum examiner who wrote an unfavorable medical opinion the Veteran is in a bad spot... HOWEVER, if a medical opinion's rationale is trash the rater CAN kick it back and either request clarification (umm hey you said medical records were silent... but pages x, xx, xxx, xxx, mentioned issues with the right knee while Veteran was in-service, can you please review and update your opinion as appropriate?) or in the cases of presumptive conditions simply override the unfavorable opinion. For presumptive conditions, it takes an Extremely detailed medical opinion to overturn a presumptive condition. Yes, VSRs should NOT be requesting medical opinions for presumptive conditions... but it happens.

If the Veteran claimed a condition as being secondary to something and the examiner provided an unfavorable medical opinion BUT there is evidence in the military medical records that the condition may have begun in service, the VA has a duty to assist to request a direct opinion.

Examiner being a bro

If the Veteran claimed a condition is directly due to their military service but the examiner states it is due to a service-connected condition instead - the rater CAN and SHOULD grant the condition on a secondary basis! While this situation is uncommon (the examiner volunteering medical opinions), it does happen.

If the examiner does a bunch of extra DBQs for you. The rater may or may not be able to grant you service-connection if appropriate. This is because unless these conditions are considered 'within the scope' of your claim, the rater is NOT authorized to raise the issues.

The matter of not being able to raise obviously service-connected conditions exists even outside of the medical examiner giving a helping hand. If the evidence of record shows a Veteran is entitled to presumptive service-connection for something - the rater CANNOT just grant service-connection in most cases!

What the rater can do is 'invite' the Veteran to file a claim for those conditions. While invitations are not always appropriately done by raters - for the most part if you see text in your decision letter that states 'you may be entitled to service-connection for X', it would be a great idea to file a claim.

NOTES:

• Scope of claim can be described as: something the VA can reasonably consider to be meant to be filed for as well.

Common examples include:

• Residual Scars from surgery of a service-connected condition;

• Claimed Hearing loss but the exam notes Tinnitus;

• Claimed Sinusitis and exam notes Allergic rhinitis (or vice-versa);

• Claimed Spine condition and the exam notes Nerve issues; and

• Claimed Diabetes and the exam notes Complications of diabetes.

IMPORTANT NOTE:

The VA has expressed through Policy that arteriosclerotic complications of Hypertension are NOT considered to be within the scope of a claim! Meaning for the VA to consider, the Veteran needs to file a claim!

Rating Decision

Now with all that time spent checking the evidence and seeing what still needs to be done, raters can now start rating.

Again, a bad rater would start here - while sure they will save a lot of time, they are doing a great disservice to Veterans. It just makes too much sense to spend those extra hour(s) if necessary to prevent denying a Veteran and having them wait months/years in appeals over something very stupid.

Before we get deeper into things I will disspell a rumor:

• IT IS FAR EASIER FOR A RATER TO GRANT SOMETHING THAN DENY!

• The VA does NOT encourage raters to deny Veterans!

• Raters do NOT look for a reason to deny!

I spend the vast majority of my time helping to ensure I can grant as many things as possible! Hell it is not my money!

Raters do not use VBMS (core) to enter decisions, raters use Veterans Benefit Mangagement System - Rating (VBMS-R); which is a sister integrated application to VBMS and R pulls data from the claim from VBMS (core) to make things easier.

When building a decision, the rater needs to input the claimed issues. Thanks to their integration, R will show a list of issues (as they appear in core). However, if a VSR missed a claimed issue then it of course will not show up. So it is again critical for a rater to personally review and check everything and not blindly trust the work of others!

To enter a decision, the rater will grab one of the issues and will either 'manually' enter a decision or select one of the rating calculators (Muscleskeletal - ankle, Hearing, etc).

In general there is no hard set rules when it comes to evaluating medical evidence; meaning raters have a fair bit of freedom when it comes to setting up the scales. Weights on the scale may include but are not limited to:

• Education of medical provider to include specialization(s);

• Length of practice;

• Depth of supporting evidence (how personalized is it - was the Veteran's specific medical records referenced or just hand waving and a mention of a study);

• Causation vs. correlation.

While yes, a rater is not a medical professional - a rater CAN weigh medical evidence. In the event the rater cannot make heads or tails of the evidence then tie goes to the Veteran's favor. This does NOT mean that if there is a one negative opinion and one favorable one than the rater needs to grant!

Granting

If after reviewing everything and it is all good, then happy days! The rater selects the appropriate rating calculator and plugs in the severity of the condition. These calculators match up exactly to the Rating schedule.

IMPORTANT NOTES:

• These rating calculators MUST be used by a rater. There is no overriding what is spits out in terms of an evaluation, with the only exception being Mental health. The mental health calculator generally spits out 3 different evaluations: One suggested evaluation and two overrides - the overrides being 1 higher or 1 lower than the suggested.

• Most evaluation criteria are black and white. Though, for things like mild, moderate, etc. severity, the rater for the most part has the freedom to weigh evidence and make a determination.

Do know that for the most part medical evidence outside of DBQs are not detailed for rating purposes and is not useful. However, a rater MUST look over everything to properly evaluate a condition. If there is conflicting evidence then the rater needs to evaluate the evidence and determine how to proceed:

• Do we need to contact the examiner for clarification?

• Does the evidence indicate the severity of the condition changed over time?

  • If so, then a Staged evaluation would be appropriate.

Service-connection, effective date, bilateral factor

After an evaluation is determined, the rater will input if service-connection for the condition is direct, secondary, etc. as well as what period of service the injury was due to (purely administrative bean counting by big VA).

Conditions that have a Bilateral factor consideration have a drop-down which the rater will select (left/right upper/lower) as appropriate.

For Effective dates, the system does have a 'helper' which spits out a suggested effective date. The system is only as good as the data in VBMS, so if things are incorrectly input into that system the helper can spit out incorrect effective dates. Furthermore, the helper... is NOT too smart, so in cases which involve anything more than basic situations - it WILL give incorrect dates! So a rater needs to pay attention to all the evidence and specifics of the claim/condition they are adjudicating!

Narrative

Once that data is all decided, it is time for the narrative of the decision for the issue.

Outside of explaining overrides, everything is auto-generated by VBMS-R thanks to the rating calculator.

Denying

If VA has exhausted its duty to assist and there are no routes to service-connection the rater can go down, the claim must be denied.

Most of the time it is not a matter of the rater not believing a Veteran's claim, just the evidence of record is not strong enough to support a claim.

While VBMS-R does offer canned language for denials (most of it being required) the rater should explain in detail why a condition is being denied. Good raters leave a roadmap behind in their decision to give a Veteran a clear direction as far as what is needed to win an appeal. But all too often raters will deny with little to no explanation.

Favorable findings are a required part of a denial - if they exist. Favorable findings boil down to the claim having 1 or more of the 3 Elements needed for the VA to grant service-connection.

Deferrals

Deferrals are not inherently good or bad things, they just mean the rater could not make a decision one way or the other due to missing evidence.

Depending how bad things turned out during the development process, it can result in a few deferrals to the an entire claim being kicked back!

When a rater defers something, they must identify ALL issues that need to be fixed in the claim. This process can be very taxing when there has been large amounts of bad/missed development. So while a rater's job is not technically to do claim development, a good rater needs to be experienced in claim development to know when errors have occurred. Unfortunately, people hired off the street as a rater who did not start as a VSR do not start with great insight on claim development, as rater training... maybe touches the littlest of pinkies into the development pool. In a perfect world that would not be too big of set-back, but with so many new VSRs it become a major issue.

Raters must input a deferral in both VBMS and VBMS-R. The deferral in VBMS are detailed instructions telling the VSR what they missed/need to do; while the deferral in VBMS-R is commonly a single sentence 'claimed condition is deferred for: record development'.

Often enough, due to the amount of time it takes to create deferrals: Most raters find it best just to complete/start the missed development issues themselves - at least in terms of ordering/requesting reworks of examinations (clarification/insufficiency). But for sending requests for records or other communications, most raters will just have the VSR do them.

Making a partial deferral (with at least 1 decision) or a full deferral (no decisions made) will result in the claim reverting back to the earlier claim status stages. It of course will also add potentially months to the length of a claim/appeal.

Return of the prodigal claim

Raters may or may not get the claim back that they previously deferred.

If a rater gets their own deferral back there is still a chance that:

• Examiner did not properly complete the rework properly;

• Rater overlooked something and finds there is still something else that needs to be done (additional deferrals to make); and/or

• VSR did not correctly complete/start all the noted deferrals.

Raters who get deferred claims from other raters may additionally find that the deferred reasons were:

• Over-development: Not relevant to a claim decision (requesting personnel records when Veteran does not have a current medical diagnosis);

• Issue raised and deferred in error (sometimes raters will erroneously raise an un/claimed issue improperly - be it due to improper form usage or the issue is outside the scope of the claim);

• Failure to make a partial decision: If the rater can grant service-connection but there is an issue determining the correct evaluation. The rater should grant and defer only the final evaluation part - that way the Veteran can get some benefits going at least, sooner than later; and/or

• Could have been a phone call/email.

  • While it is exceptionally rare, raters can and should directly contact Veterans to get clarification on simple things instead of doing a deferral.

Overall, these issues can add even more MONTHS in delays! Worse still, some examiners are SUPER dense and it may take multiple times going back and forth to get them to do their jobs properly.

Basic error check

When the rater has finished their decision, the system will do a scan to identify errors. Common errors the system identifies are:

• Veteran has a combined evaluation of 100% with no future evaluations but DEA has not been awarded;

• Statutory requirements for SMC S have been meet but not awarded;

• Common Pyramiding issues; and

• Entitlement to 38 CFR 3.324 not addressed.

Draft decision

After passing the basic error check the rater will generate a draft decision. This is to help make sure there are no errors in a decision. Obviously, this is not fool proof, but it does cut down on mistakes.

There are two parts to a draft decision:

1. Rating narrative; and

2. Rating codesheet.

1. Rating narrative

This is the rating decision you see. Raters should be proofreading everything to make sure it makes sense and to double check that a claimed issue was not overlooked. Mistakes such as contradictions regarding effective dates or evaluations should not exist!

2. Rating codesheet

The codesheet is the true backbone 'master record', which contains previous important stuff like grants, denials, current deferrals, current/past combined evaluations, etc. It is also what matters in terms of how Veterans are paid, meaning if the codesheet is wrong but the narrative is 'right', then things are not right! If a narrative is wrong but the codesheet is right, then things will be right for the Veteran - at least administratively.

So of course a rater needs to be sure their narrative matches up with their codesheet!

With experience, raters can also quickly scan a codesheet and identify previously committed Clear and unmistakable errors (CUE). At the very least, things on a codesheet that should demand a closer inspection by the rater to find out if a CUE does exist.

NOTES:

• If a rater misses a CUE done by a past rater and the file is pulled for an audit. The last rater who touched the file will be tasked to correct the CUE. Furthermore, missing the CUE will not count against that rater.

  • If a CUE is found by the rater then the discovering rater is the one who has to declare the CUE and fix the issue. If the error goes against the Veteran, due process may be required - if the error results in over-payment or severance.

  • There is no punishment for the rater who made the CUE.

Finalizing

Once everything looks good to go, the rater will finalize their deferral(s) and rating decision. This will plop a copy of both the rating narrative and codesheet into VBMS.

The claim is then sent to be promulgated and authorized and the claim stage progresses to Stage 6: Preparing Decision Letter.

Rater to group: Pist...Please send help, I haven't seen my family in months...
Richard Strange: *Plays flute* We can't be having any of that now!
Rater: Where did you come from!
Richard Strange: But... having them come in to work claims does sound like a good idea!

Zoompa, doompa (ZD): Zoompa, doompa, loompa-dee-do
Rater: Please no!
ZD: I've got a perfect puzzle for you
ZD: Zompa, doompa loompety-dee
ZD: If you are wise, you'll listen to me

ZD: What do you get when you think about escape
ZD: Dreaming that you will get out without a scrape
ZD: Where are you at? Getting terribly fat
ZD: What do you think will come of that?
ZD: I don't like the look of it

ZD: Zompa, doompa doompety da
ZD: If you're not lonely, you will go far
ZD: You will live in happiness too
ZD: Like the Oompa Loompa loompety do
ZD: Loompety do