3 Key Summer Updates to Know for VA Claims Processing

Posted August 28, 2019 by Jason Smartt, Esq., CRCR

The Veterans Administration had a busy summer in 2019. First, the Veteran Integrated Service Network allowed all facilities within their network to work claims regardless of where they originate within the network. The VISN map can be found here and select Region. Second, the VA began their Cerner implementation, which is scheduled to take 10 years. The Senate requested oversight to make sure the implementation does not go over budget or take an unnecessary amount of time. Keep in mind, the original implementation budget allotted $10 billion, before ballooning to $16 billion. The requested oversight would cost an additional $890 million. But the VA saved their most expansive change for June 6th, when the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act, otherwise known as the MISSION Act, became effective under 38 C.F.R. § 17.4000 (2019). We’re going to take an opportunity to break down how the MISSION Act changed eligibility criteria, the authorization procedure, and the claim submission process.  

The MISSION Act repelled the Veterans Choice Program and replaced it with the Veterans Community Care Program. Under the new Veterans Community Care Program, the old five eligibility conditions were altered. The old criteria would allow a Veteran to seek outside treatment when: the VA cannot provide the services, an appointment could not be made in 30 days, the Veteran lived more than 40 miles from the nearest VA, the Veteran must travel by extraordinary means, and the Veteran faced an excessive burden in traveling. Of the original criteria, four are objective and one is subjective. The MISSION Act changed the criteria to basing it on a multiple factor analysis. Those factors include: the distance between the veteran and the facility that provide potential services, nature of the care or services, the frequency of care, the potential improved continuity of care, quality of care, or whether the veteran faces an excessive burden in accessing care based on driving distance, alternative VA facilities, travel, compelling reason for alternative treatment, and the need for an attendant. The new factors should allow the VA more latitude in granting alternative care, but there are more subjective factors that could be decisive in the VA disallowing outside care.

Under the new Veterans Community Care Program, TriWest serves as the authorizing agency. TriWest is responsible for authorizing all inpatient care along with all known outpatient encounters. As it concerns emergency outpatient, transfers, and emergency inpatient claims, hospitals should attempt to acquire an authorization within 72 hours of admission and see if the VA hospital has an available bed. If there is a bed available, the Veteran must be transferred. If no bed is available, the hospital can continue to treat the Veteran while a treatment plan is authorized. The authorization guidelines remained the same but added a new wrinkle with the TriWest requirement. The MISSION Act attempts to centralize authorization functions with one entity, but it does not address the main issue of responsiveness from a VA facility regarding bed availability.

Finally, the last change deals with claim submissions under the Veterans Community Care Program. For claims that are authorized, a hospital must submit the UB to TriWest with the authorization number. The timely filing deadline is 120 days from the date of discharge. However, TriWest requests the bill within 30 days. At the same time, the hospital, at a minimum, must send the medical records to the VA within 30 days of discharge. The VA suggests that the claim be placed with the medical records so the VA will not waste time trying to marry the authorization and the medical records together. When both agencies have their respective documentation, the VA will review the medical records to confirm that the authorization matches services performed. If the VA confirms the services match the authorization, TriWest will process and pay the bill to the hospital. If the VA denies the authorization, TriWest will send a denial to the hospital. In cases where there is no authorization on file, the previous claim submission process of submitting the UB and medical records to the local VA for review and processing.

In summary, the VA made a significant regulatory change this year. First, the MISSION Act changed their program criteria for veteran eligibility to receive care from non-VA facilities. Second, the MISSION Act shifted a significant amount of the authorization responsibilities to TriWest. Finally, the MISSION Act changed the submission process for VA claims.

While veterans deserve great care, hospitals should not be left holding the bag to cover those costs. If your hospital needs assistance resolving aging A/R or reducing days to pay, consider the idea of finding a partner whose sole focus is managing these difficult claims. Review their process and be confident that the outstanding care you’re providing to our veterans is also extended to the health of your revenue cycle.