One of our experts explains the complexity of VA emergency claims this way:
If we were to examine our claims inventory by date, searching for the nagging cases lingering open the longest, it’s a good bet we’d find they’re all for emergency care where the VA is the only payer.
The Dept. of Veterans Affairs is a notoriously slow payer—despite its 2020 report to Congress aiming for the timely processing of 90% of all claims, data for FY 2019 demonstrated success only 54.6% of the time.
However, in the case of emergency care administered in a community hospital or health system, payment becomes even more elusive. A 2019 audit by the VA Office of Inspector General found that, during one six-month period, an estimated $53.3 million in emergency services at non-VA facilities was erroneously rejected or denied. This finding, they noted, likely impacted an estimated 17,400 veterans.
For its part, the VA has been transparent about efforts to streamline the overall claims process, including a long-awaited EHR rollout and a new appeals protocol. Hospitals can also improve their own odds by anticipating the hurdles and detours on the road to getting reimbursed. To avoid erroneous denials and maximize reimbursement, here’s what hospital revenue managers need to know about emergency VA claims.
The Red Flags
To begin, “rejected” and “denied” are two different outcomes in VA nomenclature. Although VA claims may be temporarily rejected for containing errors or for missing information, ER visits are frequently denied as unauthorized services.
What impacts whether an emergency claim is denied? These are red flags in the VA’s complex decision matrix:
The availability of a VA facility. Any revenue cycle manager knows that the Emergency Department is the most expensive place to receive care. If the veteran had a more economical option—a nearby VA hospital or urgent care center—the VA is less inclined to approve a visit to a community-based ED. The hospital can expect some legwork to prove that its ED was the best choice for treatment.
The injury is not clearly service-based. While the VA most certainly authorizes care for all service-based issues, veterans are expected to acquire outside coverage for their regular health needs. Did the veteran fall and break a collarbone shooting hoops, or did he fall because an old service-related back injury flared up? A hospital’s PFS staff may have to follow up with physicians to connect those dots.
The vet hasn’t received care in a VA facility in the last 24 months. The longer it’s been since a veteran required care for a service-related injury, the more difficult it will be to prove that any future ED visits are for service-related issues.
The injury was employment-related or due to a motor vehicle accident. The VA is the undisputed payer of last resort in issues of workers’ compensation or third-party liability. Proper reimbursement in these cases requires diligent work to file appropriate paperwork with multiple payers.
The filing deadline was missed. While veterans have up to two years to file claims for service-related issues, the VA’s window is only 90 days for claims that are nonservice-connected but still eligible for reimbursement. Watch this deadline for cases where the service connection is unclear.
Increasing the Odds
All that said, securing retroactive authorization from the VA for a veteran who received care in your hospital’s Emergency Department is not impossible. Revenue managers can increase their VA reimbursements by:
Notifying the VA within 72 hours. The VA requires community providers to report unauthorized emergency care via phone or email at a centralized call center within 72 hours of patient admission (for ED, outpatient, or inpatient care). Make sure your internal notification process is tight—don’t let the window close.
Collecting ALL payer sources available to the patient. In addition to asking for the patient’s supplement insurance information, determine upfront if any third-party payers may come into play. An at-fault driver’s auto insurance or an employer’s workers’ compensation payer may ultimately cover the service.
Specializing. The VA claims space is a complex web of terms, policies, and processes, and it generally takes a dedicated VA specialist to effectively navigate the process. Even with internal expertise, however, health systems generally find it’s more effective to outsource. For one 714-bed health system, for example, the Argos Health VA team collected $2.7 million more in VA reimbursement in the first half of 2020 than the internal team collected in all of 2019. And, while our team worked the VA maze, the health system redirected its internal VA claims representative to Medicare Advantage—decreasing overall Medicare Advantage AR by 50% and 180-aged accounts by 90%.
Emergency authorization is just one aspect of VA claims processing. We deconstruct the full process in our latest white paper. Download it here.
Argos Health is a KLAS top performer in the complex claims category and has been a revenue cycle partner for VA community care claims services longer than any other vendor. Our clients often see a 100% increase in overall VA payments, along with a 50% reduction in days to pay.