Chapter 16

Working with Medical Professionals

Introduction to Medical Professional Collaboration

Healthcare providers play a pivotal role in establishing secondary service connection. Their diagnoses, treatment records, and expert opinions often determine whether your claim succeeds or fails. This chapter provides strategies for effectively engaging medical professionals to obtain the documentation and support needed for successful secondary claims.

Key Concepts

Effective collaboration with medical professionals requires:

Understanding the different roles various providers can play in your claim
Communicating clearly about your needs while respecting professional boundaries
Preparing thoroughly for medical appointments
Requesting specific documentation that addresses VA requirements
Building relationships based on mutual respect and honesty

This chapter explores how to identify the right medical professionals for your claim, prepare for productive appointments, request effective documentation, and address common challenges in obtaining medical support.

Understanding Provider Roles in Secondary Claims

Different types of healthcare providers serve different functions in supporting your secondary claim. Understanding these roles helps you engage the right professionals for your specific needs.

Types of Providers and Their Contributions

Provider Type	Potential Contributions	Limitations
Primary Care Physician	Coordinates overall care Documents ongoing symptoms Provides referrals to specialists May offer general opinions on condition relationships Maintains comprehensive medical history	May lack specialized expertise for complex conditions Often has limited appointment time May be unfamiliar with VA requirements Opinions may carry less weight than specialists’
Specialists	Provides authoritative diagnoses Offers expert opinions on causation Orders specialized testing Explains complex medical mechanisms Opinions carry significant weight with VA	May have limited availability Often focused on treatment, not documentation May charge for narrative reports May have narrow focus within specialty
VA Healthcare Providers	Familiar with VA system and requirements Records directly accessible to VA claims processors No cost for treatment May document service connection discussions in notes	May be reluctant to provide explicit nexus opinions Limited appointment times Potential conflicts of interest May have high patient loads affecting documentation detail
Independent Medical Experts	Provides comprehensive evaluations Experienced in writing for legal/claims purposes Can focus exclusively on service connection questions No ongoing treatment relationship constraints Often familiar with VA requirements	Can be expensive No treatment relationship/history with you Limited to information provided May be perceived as “hired guns”
Mental Health Providers	Documents psychological impacts of physical conditions Addresses mental health secondary conditions Can explain psychological mechanisms Often skilled at narrative documentation	May focus on symptoms rather than causes Some may be uncomfortable addressing physical conditions Therapy notes may be protected differently May use different documentation standards

Selecting the Right Providers for Your Claim

The most effective approach often involves multiple providers working in complementary roles:

For diagnosis and treatment: Seek specialists in the relevant field for your secondary condition
For ongoing documentation: Engage your primary care physician to track the relationship between conditions over time
For expert opinions: Identify providers with both expertise in your conditions and willingness to provide detailed opinions
For comprehensive evaluations: Consider independent medical experts for complex cases or when other providers are unable to provide needed documentation

Strategy: Create a “provider map” identifying which healthcare professionals will fulfill each documentation need for your claim. Ensure you have coverage for diagnosis, causation opinions, ongoing symptom documentation, and objective testing.

Finding the Right Specialist

When seeking specialists for secondary conditions, consider:

Ask your primary care physician for recommendations of specialists familiar with your type of condition
Research providers who have published on the relationship between your conditions
Contact veteran service organizations for recommendations of specialists experienced with VA claims
Consider academic medical centers where providers may have more experience with complex or unusual condition relationships
When scheduling, briefly explain you’re seeking help with a VA disability claim to ensure the provider is willing to assist with documentation

Preparing for Effective Medical Appointments

Thorough preparation maximizes the value of limited appointment time and increases the likelihood of obtaining the documentation you need. This section provides strategies for preparing for different types of medical appointments.

Before the Appointment

Effective preparation includes:

Organize your medical history: Create a concise timeline of your primary and secondary conditions
Gather relevant records: Bring copies of key medical records, especially those the provider might not have access to
Prepare a symptoms summary: Document how your conditions interact and affect each other
Research condition relationships: Bring relevant medical literature if appropriate
Create a questions list: Write down specific questions about the relationship between your conditions
Draft documentation requests: Prepare specific requests for the documentation you need
Schedule appropriately: Request a longer appointment if discussing complex issues

Case Study: Effective Appointment Preparation

A veteran with service-connected diabetes sought documentation for peripheral neuropathy as a secondary condition. Before his neurology appointment, he prepared:

A one-page medical timeline showing:
- Date of diabetes diagnosis and service connection
- History of blood sugar control (A1c values)
- First symptoms of numbness and tingling
- Progression of neuropathy symptoms
- Previous treatments attempted
Copies of recent lab work and his most recent diabetic care notes
A symptom diary tracking how neuropathy symptoms correlated with blood sugar levels
A printed abstract from a study on diabetic neuropathy mechanisms
A list of specific questions:
- “In your professional opinion, is my peripheral neuropathy caused by my diabetes?”
- “What specific findings support this connection?”
- “Are there other potential causes we should rule out?”
- “How would you characterize the severity of my neuropathy?”
A written request for a medical opinion letter with specific language needed for VA purposes

This preparation allowed the neurologist to quickly understand the veteran’s history and needs. The appointment was productive, resulting in comprehensive documentation that supported his secondary claim. The neurologist appreciated the organization and specifically commented that the preparation made it possible to address all the veteran’s needs within the appointment time.

During the Appointment

Maximize appointment effectiveness by:

Stating your purpose clearly: Begin by explaining you’re seeking documentation for a VA secondary claim
Being concise but complete: Present your history efficiently using your prepared timeline
Focusing on the relationship between conditions: Emphasize how your primary condition affects your secondary condition
Describing functional impacts: Explain how the conditions affect your daily activities
Taking notes: Record the provider’s explanations about condition relationships
Asking direct questions: “Do you believe my [secondary condition] is caused by my [primary condition]?”
Making specific documentation requests: Clearly ask for the documentation you need

Strategy: Consider bringing a trusted friend or family member to appointments. They can take notes while you focus on communicating with the provider, and they may notice details or remember explanations you miss.

After the Appointment

Follow up effectively by:

Reviewing visit notes: Request copies of all documentation from the visit
Following up on promised documentation: Contact the provider’s office if expected documentation isn’t received
Addressing any inaccuracies: Request corrections to any errors in your records
Sending thank-you notes: Express appreciation for providers who provide helpful documentation
Scheduling follow-up appointments: Maintain the treatment relationship and continue documenting the condition
Implementing recommended treatments: Follow through with treatment plans to demonstrate commitment to improvement

Communication Strategies

When discussing your claim with healthcare providers:

Be honest and straightforward about seeking documentation for a VA claim
Focus on medical facts rather than financial aspects of disability benefits
Use neutral, objective language to describe your symptoms
Ask “what” and “how” questions rather than leading questions
Express appreciation for the provider’s expertise and time
Acknowledge the provider’s perspective and constraints
Be patient and persistent without becoming demanding

Requesting Effective Medical Documentation

The specific documentation you request can significantly impact your claim’s success. This section explores strategies for obtaining the most effective types of medical documentation.

Types of Medical Documentation

Different types of medical documentation serve different purposes in your claim:

Treatment notes: Document ongoing symptoms, treatments, and provider observations
Diagnostic reports: Establish the existence and nature of your condition
Medical opinions: Directly address the causal relationship between conditions
Disability questionnaires: Provide standardized information about condition severity
Functional assessments: Document how conditions affect your activities
Test results: Provide objective evidence of your condition

Nexus Letters: The Gold Standard

A nexus letter is a detailed medical opinion specifically addressing the connection between your primary and secondary conditions. An effective nexus letter should include:

Provider qualifications: The provider’s credentials, specialization, and experience
Treatment relationship: How long and in what capacity the provider has treated you
Records reviewed: List of medical records and other evidence considered
Medical history: Summary of relevant history of both conditions
Current diagnoses: Clear statement of current diagnoses with diagnostic codes
Causation statement: Clear opinion using VA standard language (at least as likely as not)
Medical rationale: Detailed explanation of the medical basis for the connection
Scientific support: References to relevant medical literature
Alternative causes: Discussion of other potential causes and why they are less likely
Severity assessment: Description of the condition’s severity and progression
Functional impact: How the condition affects daily activities and work

Case Study: Effective Nexus Letter

Below is an excerpt from an effective nexus letter for a veteran claiming sleep apnea secondary to PTSD:

[Letterhead with provider credentials]

RE: Medical Opinion for John Doe (SSN: XXX-XX-XXXX)

I am a board-certified pulmonologist with 15 years of experience treating sleep disorders. I have been treating Mr. Doe for obstructive sleep apnea since January 2022. I have reviewed his complete VA claims file, service medical records, VA treatment records, and private medical records.

Mr. Doe has been diagnosed with severe obstructive sleep apnea (OSA), confirmed by polysomnography on January 15, 2022, showing an apnea-hypopnea index (AHI) of 38 events per hour. He requires CPAP therapy nightly for treatment. Mr. Doe also has service-connected PTSD (70% disability rating), which was established in 2015.

Based on my examination of Mr. Doe, review of his medical records, and my expertise as a pulmonologist, it is my medical opinion that his obstructive sleep apnea is at least as likely as not (50% or greater probability) caused by his service-connected PTSD. This opinion is based on the following medical rationale:

1. Medical research has established multiple mechanisms by which PTSD contributes to the development of OSA. A 2018 study in the Journal of Clinical Sleep Medicine (Smith et al.) found that veterans with PTSD have a 4-fold increased risk of developing OSA compared to those without PTSD.

Sample Documentation Request Letter

[Your Name]
[Your Address]
[Your Phone and Email]

[Date]

[Provider’s Name]
[Provider’s Address]

RE: Medical Documentation Request for VA Disability Claim

Dear Dr. [Name],

I am writing to request medical documentation to support my VA disability claim for [secondary condition] as secondary to my service-connected [primary condition]. I greatly appreciate the care you have provided and would value your professional opinion on the relationship between these conditions.

Specifically, I am requesting a detailed medical opinion letter that addresses:

Confirmation of my diagnosis of [secondary condition]
Your professional opinion on whether my [secondary condition] is “at least as likely as not” (50% or greater probability) caused or aggravated by my service-connected [primary condition]
The medical rationale explaining how my [primary condition] caused or contributes to my [secondary condition]
A description of the severity and functional impacts of my [secondary condition]

To assist you, I have attached:

A summary of my medical history related to both conditions
Copies of relevant medical records you may not have access to
VA documentation confirming my service-connected [primary condition]
Medical literature regarding the relationship between these conditions

I understand that preparing this type of detailed documentation requires additional time beyond regular treatment notes. Please let me know if there are any fees associated with this request, and I will be happy to address them.

If possible, I would appreciate receiving this documentation by [date]. Please contact me at [phone] or [email] if you need any additional information or have any questions.

Thank you for considering this request. Your professional expertise is invaluable to my claim.

Sincerely,

[Your Signature]
[Your Printed Name]

When Providers Decline

If a provider is unwilling to provide the documentation you need:

Ask for the specific reasons for their reluctance
Determine if there’s a compromise (e.g., they might document observations without offering opinions)
Request a referral to another provider who might be more comfortable providing the needed documentation
Consider seeking an independent medical examination from a provider who specializes in disability evaluations
Consult with a veterans service officer about alternative approaches

Remember that providers have different comfort levels with disability documentation. A refusal is not necessarily a reflection on the validity of your claim.

Working with VA Healthcare Providers

VA healthcare providers present unique opportunities and challenges for secondary claims documentation. This section provides strategies for effectively working within the VA healthcare system.

Understanding VA Provider Constraints

VA healthcare providers operate under specific constraints that may affect their ability to provide documentation:

Dual roles: They provide both healthcare and documentation that affects VA benefits
Time limitations: Often have limited appointment times and high patient loads
Documentation policies: May have guidelines about providing opinions for claims
Perceived conflicts: May be concerned about conflicts of interest
System familiarity: Understand VA requirements but may be cautious about direct opinions

Effective Strategies for VA Providers

To maximize documentation from VA providers:

Focus on treatment documentation: Ensure your ongoing symptoms and their relationship to your primary condition are documented in regular treatment notes
Ask direct questions: “Do you think my back pain is contributing to my depression?” allows the provider to document their response
Request specific testing: Ask for objective tests that might demonstrate the connection between conditions
Discuss medical literature: Bring relevant research for the provider to consider and potentially reference
Use DBQs when possible: Request completion of Disability Benefits Questionnaires for your conditions
Build relationships: Establish ongoing care relationships with providers who understand your conditions
Request referrals: Ask for referrals to specialists who can provide more detailed evaluations

Strategy: Focus on getting factual observations documented in VA treatment records rather than explicit opinions. For example, a note stating “Patient’s depression symptoms worsen when back pain increases” documents an observed relationship without requiring the provider to make a direct causation statement.

Accessing and Using VA Medical Records

VA medical records are directly accessible to claims adjudicators, making them particularly valuable:

Request regular copies: Obtain copies of your VA medical records regularly to review for accuracy
Address inaccuracies: Request corrections to any errors through the proper channels
Highlight relevant entries: In your claim, specifically reference relevant VA treatment notes by date and provider
Connect the dots: In your personal statement, explain how VA records support your claim
Use the Blue Button: Access your records through the VA’s online portal
Request complete records: Ensure you have all records, including those from different VA facilities

Case Study: Effective Use of VA Records

A veteran with service-connected knee injuries sought secondary service connection for lumbar strain. Rather than requesting a direct opinion letter from his VA primary care physician, who had expressed reluctance to provide such documentation, he took this approach:

At each appointment over six months, he specifically mentioned how his altered gait from knee pain was affecting his back
He requested his provider document his observed limping and its severity
He asked for a referral to physical therapy, where the therapist documented the biomechanical relationship between his knee and back issues
He requested an X-ray of his spine, which showed degenerative changes
When discussing treatment options, he asked questions like “Is my knee condition contributing to my back problems?” allowing the provider to document their response
He obtained copies of all these records and highlighted the relevant entries
In his claim, he created a timeline showing how his VA records documented the progression from knee problems to back issues

While no single VA record explicitly stated that his back condition was secondary to his knee condition, the collective documentation created a clear picture of the relationship. His claim was approved based on the consistent documentation in his VA records, even without a formal nexus letter.

VA Community Care Providers

VA Community Care providers (non-VA providers who see veterans through VA referrals) can be valuable resources for documentation:

They have more independence than VA-employed providers
Their records become part of your VA medical record
They may be more willing to provide detailed opinions
They often have expertise in specific conditions
Request Community Care referrals when appropriate specialists aren’t available at your VA facility

Working with Independent Medical Experts

When treating providers cannot or will not provide the documentation needed, independent medical experts (IMEs) can be valuable resources. This section explores strategies for effectively engaging these professionals.

When to Consider an Independent Medical Expert

Consider seeking an IME when:

Treating providers are unwilling to provide opinions on causation
Your case involves complex medical relationships requiring specialized expertise
You need to counter negative C&P examination findings
There are conflicting medical opinions in your record
You’re appealing a denied claim and need stronger medical evidence
You lack treatment records documenting the relationship between conditions

Types of Independent Medical Experts

Different types of IMEs serve different purposes:

Independent medical examiners: Conduct physical examinations and provide opinions
Medical record reviewers: Provide opinions based on record review without examination
Subject matter experts: Specialists with particular expertise in your conditions
Vocational experts: Address functional impacts and employability
Medical researchers: Provide opinions based on current scientific understanding

Finding and Selecting an IME

To find an appropriate IME:

Consult veterans service organizations: Many maintain lists of IMEs experienced with VA claims
Ask veterans law attorneys: Attorneys often work with IMEs regularly
Research medical experts: Look for professionals who have published on your conditions
Check professional directories: Many specialties have directories of providers who perform evaluations
Consider academic medical centers: Faculty physicians may provide expert opinions
Evaluate credentials carefully: Look for board certification and relevant experience

Strategy: When selecting an IME, prioritize relevant expertise and experience with VA claims over convenience or cost. An expert with specific knowledge of your conditions and VA requirements will provide more valuable documentation.

Preparing for an IME Evaluation

To maximize the value of an IME evaluation:

Organize records chronologically: Provide complete, well-organized medical records
Prepare a medical summary: Create a concise overview of your medical history
Clarify expectations: Discuss exactly what documentation you need
Provide VA context: Share information about your service-connected conditions
Be transparent: Disclose all relevant medical history, even potentially unfavorable information
Address costs upfront: Understand and agree to the fees before proceeding
Request a comprehensive report: Specify the elements needed in the final documentation

Case Study: Effective IME Engagement

A veteran with service-connected PTSD had been denied service connection for hypertension as a secondary condition. His treating providers documented his hypertension but were unwilling to provide opinions on causation. He engaged an independent cardiologist with experience in VA claims and took these steps:

Provided a complete set of organized medical records, with a chronological summary highlighting:
- Date of PTSD diagnosis and service connection
- Documentation of PTSD symptoms and severity over time
- First elevated blood pressure readings and their relationship to PTSD symptoms
- Progression of hypertension and treatment history
- Absence of hypertension prior to PTSD
- Absence of other risk factors (normal weight, no family history, non-smoker)
Included three relevant medical studies on the relationship between PTSD and cardiovascular disease
Provided the VA’s denial letter to address the specific reasons for denial
Requested a comprehensive evaluation addressing:
- Confirmation of hypertension diagnosis
- Medical opinion on causation using VA language
- Detailed explanation of the physiological mechanisms
- Discussion of how his case fits established patterns
- Rebuttal of the VA examiner’s negative opinion

The cardiologist provided a detailed 8-page report explaining how PTSD causes hypertension through chronic sympathetic nervous system activation, hypothalamic-pituitary-adrenal axis dysregulation, and inflammation. The report cited multiple studies, addressed the veteran’s specific case, and directly rebutted the VA examiner’s opinion. Upon appeal with this new evidence, the veteran’s claim was approved.

Cost Considerations for IMEs

Independent medical evaluations can be expensive, typically ranging from $500 to $2,500 depending on the complexity and the expert’s qualifications. Consider these approaches to managing costs:

Ask if the expert offers reduced rates for veterans
Inquire about payment plans or sliding scale fees
Consider record review opinions, which are typically less expensive than in-person evaluations
Explore whether veterans service organizations can assist with costs
If working with an attorney, discuss whether they can advance the cost as part of representation
Weigh the cost against the potential long-term value of disability benefits

Remember that a high-quality IME opinion can be decisive in complex cases and may be worth the investment, particularly for conditions with significant disability ratings.

Addressing Common Challenges

Veterans often encounter challenges when seeking medical documentation for secondary claims. This section provides strategies for overcoming common obstacles.

When Providers Are Reluctant to Provide Opinions

If providers are hesitant to provide causation opinions:

Understand their concerns: Ask about specific reservations
Provide educational materials: Share information about VA requirements
Suggest documentation alternatives: Request factual observations rather than opinions
Offer research support: Provide relevant medical literature
Request referrals: Ask for referrals to providers who might be more comfortable providing opinions
Consider independent experts: Seek providers who specialize in disability evaluations
Focus on treatment documentation: Ensure symptoms and their relationship to your primary condition are well-documented

Strategy: If a provider is uncomfortable providing a direct causation statement, ask if they would be willing to document factual observations about the relationship between your conditions. For example, “I observe that the patient’s migraine frequency increases during periods of heightened PTSD symptoms” documents a correlation without requiring a definitive causation statement.

When Medical Records Are Incomplete

If you lack comprehensive medical documentation:

Request historical records: Obtain records from all previous providers
Fill documentation gaps: Schedule appointments to establish current status
Create a medical timeline: Document the progression of conditions even if records are missing
Provide lay evidence: Submit detailed personal statements about symptom history
Seek buddy statements: Obtain statements from witnesses who observed your conditions
Request record reconstruction: Ask providers to document historical information based on your reports
Consider IME record reviews: Experts can sometimes draw conclusions despite incomplete records

When Facing Negative C&P Exam Opinions

If a VA examiner provides a negative opinion:

Request the exam report: Obtain a copy to identify specific issues
Identify factual errors: Note any inaccuracies in the examiner’s understanding of your history
Address methodology issues: Identify any inadequate examination procedures
Obtain countering opinions: Seek opinions that specifically address the examiner’s conclusions
Provide research evidence: Submit medical literature that contradicts the examiner’s rationale
Request a new examination: If the exam was clearly inadequate, request another
Consider IME rebuttal: Obtain an expert opinion specifically addressing the C&P exam findings

When Facing Financial Constraints

If cost is a barrier to obtaining needed documentation:

Prioritize VA healthcare: Maximize documentation through the VA system
Request fee waivers: Ask providers about reduced fees for veterans
Explore VSO resources: Some organizations provide financial assistance
Consider medical schools: Teaching hospitals may offer reduced-cost evaluations
Focus on record reviews: These are typically less expensive than in-person evaluations
Request payment plans: Many providers will accommodate payment over time
Explore pro bono services: Some providers offer free services to veterans in need

Final Thoughts on Working with Medical Professionals

Successful collaboration with medical professionals requires patience, persistence, and mutual respect. Remember these key principles:

Build Relationships

Invest time in developing ongoing relationships with providers who understand your conditions and are willing to support your claims. These relationships are more valuable than one-time evaluations.

Be Prepared

Thorough preparation demonstrates respect for providers’ time and increases the likelihood of obtaining the documentation you need. Organization is key to successful medical appointments.

Understand Boundaries

Recognize that healthcare providers have ethical and professional obligations that may limit what they can document. Work within these boundaries rather than pressuring providers to exceed their comfort level.

Focus on Facts

Emphasize objective, factual documentation rather than seeking opinions that providers are uncomfortable providing. Consistent factual observations can be as powerful as direct opinions.

Expert Tip

The most successful veterans approach medical documentation as a collaborative process rather than a transactional one. By focusing on building relationships with providers who understand both your medical conditions and your needs as a veteran, you create an environment where comprehensive, accurate documentation becomes a natural extension of your healthcare rather than an additional burden.