From Uncertainty to Expertise: How ERN Is Building AI-Ready Leaders in a Rapidly Changing Landscape (VA)

As artificial intelligence continues to reshape industries at an unprecedented pace, uncertainty in the workplace has become the norm rather than the exception. At ERN, that anxiety is being met with a deliberate strategy: investing in people.

By developing employees into autonomous subject matter experts who can navigate regulatory complexity, collaborate effectively, and lead with confidence, ERN is redefining what it means to thrive in an AI-driven world. In a recent conversation, President Ed Norwood sat down with one of ERN’s SMEs, Demetrio Bazan, to explore how deep expertise—particularly in areas like the VA Appeals Modernization Act and Higher-Level Review—translates into real-world impact, faster resolutions, and a new standard of professional excellence.

1. “Can you walk us through your experience working TriCare, ChampVA, TriWest, and VA cases through the new Higher-Level Review (HLR) process—and what kind of success you’ve seen so far?”

TRICARE and TRIWEST do not go through the HLR process, as they are third-party payors; they go through their own appeals process. However, although CHAMPVA is a third-party payor as well, they are also a branch of the VA through the Veterans Health Administration (VHA) Office of Integrated Veteran Care (IVC), which is responsible for processing CHAMPVA applications, determining eligibility, authorizing benefits, and processing medical claims. Therefore, CHAMPVA cases are able to go through the HLR.

So far, this process is a success as we’ve seen back-to-back months of high overturn ratios on behalf of the providers through claim representation.

2. “For those who may not be familiar, how does the Appeals Modernization Act shape the HLR process, and what are the key laws or principles providers need to understand to be effective?”

The Office of the Inspector General of the VA conducted an audit report # 18-06294-213 on November 21, 2019, and revealed that the VHA has not effectively managed appeals. This mismanagement led to the Appeals Modernization Act (AMA), which paved the way for three distinct, faster, and specialized lanes:

• Supplemental Claim
• Higher Level Review
• Board of Veterans Appeals

The provider had one year from the date of the initial decision letter (aka denial) to file an appeal; however, the provider can file a Supplemental Claim at any time with new and relevant evidence to reopen the claim.

3. “Approximately how many cases have you personally worked through the HLR process, and what trends are you seeing in how the VA is reviewing and responding to these cases?”

Since December 2025, to today’s date, 04/15/2026, approximately 351 cases have been sent to the Higher-Level Process, and 20 cases have been overturned, with the majority still pending. All 20 cases have been ambulance cases; we have yet to see a hospital claim be overturned.

When it comes to High-Dollar hospital cases, the VA sends a letter back stating that I am not a properly appointed VA representative and requests that I refile along with another form, VA form 21-22a.

I would then rebut via email, advising the reviewer that I attached the ERN/TRAF Statement of Representation (“SOR”), which was also attached to VA Form 20-0996 upon claim submission, informing the reviewer that, according to HIPAA laws, VA Form 20-0996 and the SOR are legally sufficient to overturn denials and process claims for payment.

As you can see from our high overturn ratio, it is accurate.

4. “What has been your experience with response times from the VA under HLR—are you seeing faster resolutions compared to traditional appeals?”

Yes, absolutely. According to the VA, the Higher-Level Review response timeframe varies between 3-4 months. However, I have received responses within 2 weeks upon appeal submission.

5. “What’s the oldest or most complex case you’ve successfully overturned through HLR, and what administrative law strategy made the difference in that outcome?”

The oldest and somewhat complex case I overturned through the HLR process was for a veteran whose DOS was in June 2024. What made it complex was that this was a non-emergent ambulance transport from a non-VA facility, nor a CCN provider. There are more Federal laws that cover ambulance transportation between a VA facility and/or a CCN provider hospital; however, this was not the case in this scenario, which made it challenging.

The Federal statutes that were used in this case were:

38 CFR § 70.71(b)(1)-(3)

(b) Enrolled veterans. Regardless of a veteran’s eligibility for beneficiary travel, VA may provide VTS to veterans enrolled in VA’s health care system who need transportation authorized under § 70.72 for:

(1) A scheduled visit or urgent care;

(2) Retrieval of, adjustment of, or training concerning medications and prosthetic appliances, or a service dog (as defined in 38 CFR 17.148);

(3) An unscheduled visit;

And 38 CFR § 70.72

(d) Other locations. VA facilities may use VTS to provide scheduled or unscheduled transportation to and/or from a VA or VA-authorized facility or other places when a VA clinician has determined that such transportation of the veteran, servicemember, their attendant(s), or CHAMPVA beneficiary receiving benefits through the CITI program would be needed to promote, preserve, or restore the health of the individual and is in accord with generally accepted standards of medical practice, as defined in 38 CFR 17.38(b).

Here, I informed the VA that the veteran required medically necessary transportation after being treated for his regularly scheduled appointment, making our veteran weak and a fall risk due to his ongoing radiation treatments. Regardless of the veteran’s eligibility for beneficiary travel, he qualified for the Veterans Transportation Service (VTS).

We closed the argument by requesting the VA to release the federal funds intended for the veteran and provide the health care services promised by President Lincoln, to care for those who have served in our nation’s military and for their families, caregivers, and survivors.

If you are a healthcare provider struggling with the VA Higher Level of Review Process and need representation, please email the undersigned for immediate assistance.

Demetrio Bazan IV
ERN/TRAF VA Specialist
ERN/TRAF – The Reimbursement Advocacy Firm
Email: demetriobazan@ernenterprises.org