Last year, the Argos team recovered $3.5 million more in reimbursement for a health system by advocating for one critical change: adding another VA payer into the EHR and billing system.
The change didn’t initially make intuitive sense to the health system, which argued that the VA should be treated as a single entity. With the passing and implementation of the MISSION Act, it is important to note that VA and military claims are processed by several different administrators. Hospitals should expect to use two or three different payer IDs to maximize VA claims processing.
Does it really make a difference if claims are initially misdirected?
Unequivocally, yes—every second a claim wastes in the inbox of the wrong payer becomes lost time and revenue. The effect is compounded when claims turn out, as they sometimes do, to be the responsibility of a payer other than the VA.
As a leading complex claims vendor, a critical component of our service is tracking down the correct payer for each claim. This quick primer outlines what is at stake for a health system when no one is watching the payer trail.
More than 20 years ago, the Millennium Act allowed veterans, under certain conditions, to seek emergency treatment from their community hospitals. VA hospital claims for unauthorized emergency care go directly to the VA.
TriWest and Optum
In 2018, the Mission Act created the Community Care Network to allow veterans to access treatment for service-related conditions from their community hospitals. Again, certain conditions apply.
TriWest and Optum are the third-party administrators for the Community Care Network. Generally speaking, Optum covers the regions in the Eastern U.S. and TriWest covers regions in the Western U.S. Hospital claims for authorized care as part of the CCN go to the designated TPA for the region.
Here’s where it gets complicated: TriWest initially managed claims for the entire country before Optum was brought on to share the load. Hospitals in regions affected by the Optum switchover may have older claims that still go to TriWest while newer claims are sent to Optum.
Many hospitals also mistakenly send all claims to the TPA, but as outlined above, emergency claims still go directly to the VA. Hoping for Optum to forward emergency claims over to the VA is not a reliable reimbursement strategy. Complex claims specialists work with health systems to build the proper channels for claims to bill correctly out of the gate.
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. These claims go to the VA.
Tricare is the insurance plan for active-duty military and their families. Hospitals have been known to confuse Tricare West (a regional designation for Tricare) with TriWest (one of the third-party administrators for the CCN). That mistake can add months of delay to the claims process—those two payers operate in nowhere near the same claims space.
Further, while 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 just to treat issues related to that injury.
Other Health Insurance (OHI)
Patients may be veterans, but hospitals frequently have a long road ahead to prove that the VA is responsible for the care they received. If the illness or injury happened at work, was a result of a car accident, or was due to the negligence of a third party, the VA is the recognized payer of last resort.
A complex claims specialist with multiple service lines can easily pursue other payers who may be responsible for the claim, including Medicare, third-party commercial insurance, or employer-sponsored workers’ compensation. This likely includes working with hospital PFS teams to secure the appropriate clinical documentation.
The Right Path
So, how would a hospital know if it’s losing claims along the payer trail?
Take the case of an 83-bed hospital with 102 VA claims per year. On average, 26 were being sent to self-pay and 20 were completely written off.
After outsourcing, one visit became self-pay and zero visits were written off.
Learn More: We deconstruct the full VA claims 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.