Out of State Nexus Letter or DBQ: Fraud or Ethical Requirement?

Will the VA throw out your nexus letter or disability benefits questionnaire (DBQ) if you get it from a provider in a different state than you live in? Psychologist Dr. Todd Finnerty gives his impressions.

Here is the Psychology Interjurisdictional Compact (PSYPACT) map (these are all the states where PSYPACT psychologists can do telehealth exams to legally): https://psypact.site-ym.com/general/c...

You might also be interested in some ethics code references just in case (these apply to psychologists):

APA Specialty Guidelines for Forensic Psychology: https://www.apa.org/practice/guidelin...

Here is an ethics code blog post summarizing the ethical guidelines above: https://nexusletters.com/2021/11/29/t...

Here is a quick snippet that is relevant:

4.02.01 Therapeutic-Forensic Role Conflicts
Providing forensic and therapeutic psychological services to the same individual or closely related individuals involves multiple relationships that may impair objectivity and/or cause exploitation or other harm. Therefore, when requested or ordered to provide either concurrent or sequential forensic and therapeutic services, forensic practitioners are encouraged to disclose the potential risk and make reasonable efforts to refer the request to another qualified provider. If referral is not possible, the forensic practitioner is encouraged to consider the risks and benefits to all parties and to the legal system or entity likely to be impacted, the possibility of separating each service widely in time, seeking judicial review and direction, and consulting with knowledgeable colleagues. When providing both forensic and therapeutic services, forensic practitioners seek to minimize the potential negative effects of this circumstance (EPPCC Standard 3.05).

...and a "VHA directive" that is consistent with this snippet:
VHA Directive 1134(2) Provision of Medical Statements and Completion of Forms by VA Health Care Providers recommends that VA mental health treatment providers not complete forms such as “mental health DBQ’s” in order to “maintain the integrity of the patient-provider relationship.” Therefore, both the VA and Veterans often must seek forensic specialists outside of a treatment relationship to provide opinions related to their case.

The OIG may be concerned about fraudulent DBQ's or nexus letters, and with good reason given that there has likely been instances of fraud, but the reality is that the system is set up so that ethically treatment providers are not constantly tasked with impacting the treatment relationship by having to potentially advocate for their patient in a potentially biased way providing disability opinions (see what I did there?).

In addition, we live in a world where second opinions are needed. Per the VA’s own OIG “some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims.“ The OIG found that the contractors QTC, VES and LHI “failed to consistently provide VBA with the accurate exams required by the contracts.” The OIG notes that “ALL THREE VENDORS HAVE BEEN BELOW THE CONTRACT’S 92% ACCURACY REQUIREMENT SINCE AT LEAST 2017.” Most errors– including a significant number that “had the potential to affect claims decisions–” aren’t corrected before the claims processors decided the claims per the OIG. https://www.va.gov/oig/publications/r...

The VA’s own researchers have also identified contract exams as being plagued with errors. The VA researchers noted “there are several possible explanations for the observed deficiencies in contract exams, including lack of supervision, more limited access to VA treatment records, and inadequate training and experience. An additional explanation is that, unlike exams by salaried VA staff, contractors are paid a flat fee for each exam which is a small fraction of the typical fees paid for forensic psychological evaluation in the community. Thus, there is a financial incentive to complete exams quickly, which would preclude careful record review, psychological testing, and detailed report preparation.” The authors go on to suggest that “anecdotally, it is not uncommon for veterans seen by contractors needing to be reexamined, at times with requests for second and even third opinions to resolve “conflicting medical evidence” after a contract examiner rendered an opinion that contradicted those in the veteran’s records or in previous C&P exams. Inefficiencies resulting from poor exams increase the workload for both examiners and VBA personnel and increase the costs for VA C&P operations overall.” https://psycnet.apa.org/record/2022-7...

VA disability claims shouldn't be, but sometimes are adversarial & mistakes get made. Veterans can obtain unbiased second opinions when needed.