The VA has a language all its own for the hospital claims process. What’s more, many of the VA terms are confusing, easily mistaken one for another, or even mean something different in another financial sector.
In other hospital service lines, small semantics issues may be fairly easily remedied. For VA hospital claims, however, confusing “notification” with “authorization,” or mixing up TriWest and Tricare West, can cost a health system millions of dollars in unrecovered reimbursement.
While mastering the complexities of VA hospital claims is an arduous process, the following glossary is a start. Organized conceptually rather than alphabetically, it serves as an “Intro to VA Claims” for the Patient Financial Services team.
In effect for more than 20 years, the Millennium Act laid the groundwork for the VA to pay for a veteran’s care even though it might not be directly service-related. The act authorizes the Dept. of Veterans Affairs to consider reimbursement to a health care provider for the “reasonable value” of emergency treatment furnished to a veteran for non-service-related conditions, provided that all criteria for reimbursement are met.
PFS representatives will often see a claim’s status listed as “Pending a Mill Bill ruling.” This indicates that the VA is currently reviewing the claim to confirm that it does, in fact, meet all the criteria outlined by the VA for reimbursement of non-service-related emergency care.
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). Notably, the clock starts when the patient arrives at the facility, not after the patient is discharged. Hospitals that miss the 72-hour notification window should expect that claims resulting from that veteran’s treatment will be denied. Note: Notification does not replace the need for authorization (see “Authorization” below).
While the Millennium Act provided for non-service-related emergency care, the Mission Act of 2018 made it possible for veterans to receive service-related care from non-VA facilities. To be eligible to seek care from a community-based hospital or clinic, the veteran must meet certain criteria (see “Authorization).
Community Care Network
To make it easier for veterans to access care from local community hospitals, the Mission Act created the Community Care Network (CCN). It divides the nation into six regional networks, which provide the framework for the VA to purchase care for veterans from community-based facilities.
Although the Mission Act now allows veterans to seek care for service-related conditions outside of a VA hospital, the VA must still authorize the care in advance. The VA evaluates cases against six eligibility criteria. The veteran must meet one of the six in order to receive authorization.
Notably, authorization applies to emergency care and the Millennium Act, as well. Emergency care still requires authorization, but it is granted retroactively after notification. Without authorization, claims are relegated to the laborious unauthorized care review system, which generally requires months or even years of diligent follow-up to achieve a resolution. Further, hospitals will need authorization in order to be reimbursed for lab tests, imaging, or any care provided in the in-patient setting beyond just the minimum required to stabilize the patient.
Traditional VA Coverage
The care facilitated by the Mission Act is for service-related injuries or illnesses, which are reimbursed under traditional VA coverage. Non-service-related emergency care may also be reimbursed under traditional VA coverage (see “Millennium Act”). For all other care—routine visits, annual screenings, treatment for illness that is not service-related—the VA expects veterans to carry other health insurance, such as Medicare or an employer-sponsored commercial health plan.
TriWest and Optum
TriWest and Optum are the third-party administrators for traditional VA coverage under the Community Care Network. Generally speaking, Optum covers the regions in the Eastern U.S. and TriWest covers regions in the Western U.S. Hospitals must send authorizations and claims to the correct administrator for their designated regions.
Claims that don’t meet the criteria for reimbursement, and/or that did not receive authorization from the VA, are denied as unpayable. Upon denial, complex claims specialists pursue other payers who may be responsible for the claim—employer-sponsored commercial insurance, Medicare, third-party payers (in the case of accidents or workplace injuries), etc. They may also work with hospital PFS teams to secure the appropriate clinical documentation to appeal the denial and get retroactive approval.
The VA “rejects” claims that are missing critical information or contain billing and coding errors (see our recent blog post “10 Reasons Why VA Hospital Claims are Rejected”). While rejected claims can be corrected and resubmitted for payment, hospitals face considerable financial impact from failing to submit claims correctly from the start. A 2019 report from the VA Office of the Inspector General (OIG) revealed that the VA had been storing thousands of rejected claim appeals in boxes and file cabinets without processing them. The average unprocessed appeal had been pending for 710 days.
Tricare is the insurance plan for active-duty military and their families. Because it functions just like any employer-sponsored health plan (with co-pays, deductibles, etc.), and because it covers non-service-related routine care, Tricare claims are not typically considered part of the “complex claims” category.
However, some confusion arises for the intake and billing teams when hospitals group Tricare together with the VA as military insurance. Hospitals have also been known to confuse Tricare West (a regional designation for Tricare) with TriWest (one of the third-party administrators for traditional VA coverage). That mistake can add months of delay to the claims process.
Further, military retirees and veterans may look the same to a patient intake representative. They are not. A service member who retired from active duty with the military is covered by Tricare for routine care. VA coverage is for veterans who were injured in the line of duty and, with certain exceptions, is used to just treat issues related to that injury.
ChampVA coverage is exclusively for the spouses and children of veterans who were disabled in the line of duty. It provides for the care of families when a veteran can no longer generate income as a result of their service.
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.