VA and other complex claims are great opportunities for providers to outsource. These claims represent a smaller percentage of claim volume that requires outsized efforts to properly bill and collect. The complexity of the VA claim process begins prior to a patient seeing a community care provider. Understanding the variables of this process can help providers make informed decisions are patient claims and administrative processing. The VA emphasizes that their community care programs are not health insurance – they are purchase programs. This difference means that providers need to process VA patient claims differently than other claims. Eligible veterans and their families purchase healthcare services from a participating VA community care provider following an eligibility and authorization process. Unfortunately, this is not a singular process, but multiple processes based on several factors.
The VA contractor can determine the authorization process for patient and providers. TriWest manages the VA community care provider system in the mid-west and west coast. Their forms and systems are exclusive to those areas. The east coast and the central United States was managed by HealthNet until September 2018. Following unsatisfactory administration and patient experiences, the VA decided to terminate their contact with HealthNet. All administration for HealthNet service area providers and patients was transferred to the VA community care office. This transfer forced the reauthorization for all previously approved treatment, as well as the forced renewal of community care providers under the VA. Managing a continuation of treatment and adjusting claim filing processes during the HealthNet and VA transition process is ongoing. Argos Health can assist providers with claims denials associated with this transition and provide claim processing support.
The VA has several purchase programs for medical services. The two main programs are Patient-Centered Community Care (PC3) and Veteran’s Choice Program (VCP). PC3 is a national network of providers where eligible veterans can receive primary and specialist care, mental health, and limited emergency and maternity/newborn care. The VCP program is specifically for granting veterans access to medical services when wait-listing or limited treatment locations create an undue burden on the patient. Since both programs provide access to community care providers for difference reasons, the factors for eligibility and the processes for authorization are likewise difference. While a provider may participate in one program, they may not necessarily participate in both programs. It could then become necessary for a provider to know under which program a patient has been determined eligible for treatment prior to providing services.
Additional authorization and scheduling factors include the day of the week or time of day of the application, geographic location, the necessity of care, and whether it is a service-connected injury or illness. All of the considerations affecting authorization and scheduling has created a complicated and clumsy system. Generally, providers will be contacted by a VA contractor or the VA community care coordinating office to schedule care already authorized by the VA under one of the purchased care programs. This means the patient has already waded through a large amount of processing and approvals by the time they see the provider.
Once the authorization is approved, providers receive a detailed notification packet prior to a veteran’s initial visit, with VA specific instructions related to documentation and treatment reporting requirements, notification processes, requirements for communication with the veteran, etc. Diligent adherence to these instructions and requirements are necessary for clean and timely claim processing. It is important to remember that the VA will only cover treatment described in the notification packet. Any additional care determined to be necessary will require additional authorization.
Providing additional treatment outside the parameters of the provider packet could result in unauthorized care. If a veteran obtains care without prior authorization, it could result in a denied claim. In limited circumstances, VA may pay for care that is unauthorized. However, non-emergency, unauthorized care runs the risk of being denied by the VA leaving the patient to pay for all or part of the care. The inherent complexity and the likelihood of continuing charges, make VA community care claims a great candidate for outsourcing.
Argos Health is a leader in VA and other complex claim outsourcing services. We have collected millions of dollars on thousands of VA claims for clients. Argos has extensive experience working across geographic regions with multiple VA contractors. This experience has developed the knowledge and relationships required to effectively resolve VA claims. Argos Health offers a “Day of Discharge” assignment for VA claims. This allows our experts to immediately respond to claim filing for a prompt and proper delivery of the claim to the VA. Our team will verify the receipt of delivery with the VA and perform routine follow-up for a prompt resolution. Trusting Argos Health with VA claims will mean fewer denied claims and less stress on a provider’s internal staff. Our team and advanced technology provide clients with relief and knowledge that their VA claim process will be handled correctly.