With the passage of the MISSION Act in 2018, the Veterans Community Care Network was launched to make it easier for veterans to access care from their local community hospitals. In turn, two deceptively simple terms governed how those hospitals could be reimbursed for the services they provided: Authorization and Notification.
“Deceptively simple” is the operative phrase, as the two terms are frequently misunderstood or even mixed up one for the other. The resulting confusion unfortunately has a considerable impact on a hospital’s revenue cycle and overall rate of reimbursement for VA hospital claims.
Authorization is the more straight-forward concept of the two. Essentially, even though a veteran now has the option to seek care from a hospital or clinic that is not a VA facility, the VA still must approve that care via an authorization. It’s not a guarantee, however—the veteran must meet one of these six criteria set forth by the VA to determine eligibility:
- The veteran needs a service not available at a VA medical facility. The VA doesn’t provide maternity care, for example.
- The veteran lives in a U.S. state or territory without a full-service VA medical facility. Specifically, this applies to residents of Alaska, Hawaii, New Hampshire, and several U.S. territories.
- The veteran qualifies under the “Grandfather” provision related to distance eligibility for VCP. The Veterans Care Program is the old system that was replaced by the Veterans Community Care Network after the passage of the MISSION Act.
- The VA cannot provide care within certain designated access standards. This refers both to travel distance and to the number of days a veteran would have to wait to get an appointment at a VA facility.
- Authorization is in the veteran’s best medical interest, such as when seeing a specialist.
- A VA service line does not meet certain quality standards. This is limited, however, and is subject to additional determinants.
All this becomes exponentially more complicated in the case of emergency care, which brings us to the second term.
By definition, emergency care is unexpected, and therefore the veteran is most certainly arriving at the hospital without prior authorization. In those cases, the VA requires notification.
More specifically, for hospitals to have a chance at receiving reimbursement for unauthorized emergency care, they must notify the VA within 72 hours. The VA expects to follow veterans through all courses of care, so they need to know when veterans present at non-VA facilities.
Notification may be made over the phone or via email to the VA’s centralized call center, but here’s the key: The clock starts when the veteran arrives at the facility, not after discharge.
Numerous hospitals get no further than that—they miss the notification window and face certain denial. Others pass the notification test but don’t realize they should still seek authorization.
No, notification doesn’t replace authorization. Emergency care still requires authorization, which can be granted retroactively after notification. Without authorization, claims are relegated to the unauthorized care review system, which operates at the VA’s notorious snail’s pace. (Our recent blog post outlines the many reasons emergency claims may be rejected or denied.)
Further, considerable effort may be required to justify any payment for treatment beyond the minimum necessary to stabilize the patient. In other words, hospitals will need authorization in order to be reimbursed for lab tests, imaging, or care provided in the in-patient setting following the emergency intervention.
The complexity of these two critical VA terms leads us to recommend a third:
Most hospitals find that navigating the VA claims process is best accomplished by a dedicated VA specialist, either internal or outsourced, who can focus exclusively on mastering the VA’s regulations and processes.
Until recently, hospitals that didn’t have a VA strategy with dedicated PFS resources often considered it more cost-effective to write off complex VA claims rather than sink resources into recovering reimbursement. With the implementation of the MISSION Act, those days are behind us. As U.S. Senator Jerry Moran (R-Kan.) noted in his February 2020 address to Congress, the number of veterans seeking care in community hospitals is expected to increase from 648,000 to 3.7 million. Further, according to the most recent U.S. population statistics, veterans represent nearly 44% of all men in the U.S. over the age of 75—the age group most likely to need hospital care.
The numbers point to the inevitability of a dramatic increase in VA hospital claims. Hospitals that aren’t preparing to accommodate the influx are already behind.
Notification and Authorization are just the first steps to VA reimbursement. We deconstruct the full VA hospital claims 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. Learn more about our VA claims services by going here or filling out our contact form.