1. Confusion over patient eligibility
The VA’s changing programs, a lack of understanding of eligibility criteria, and limited information on the specific resources and services available have long frustrated healthcare providers, likening the VA system to a “black box” that can only be accessed by people within.
For a Veteran to qualify for community care, they need to meet one of the following criteria:
- The medical service is not available at a VA medical facility
- The state or territory does not have a full-service VA medical facility
- The Veteran qualifies under the “Grandfather” provision related to distance eligibility
- The VA cannot provide care within certain designated access standards
- It is in the Veteran’s best medical interest
- A VA service line does not meet certain quality standards
In most cases, providers receive detailed referral information before the Veteran’s initial visit, with specific details on what the VA will cover. If it is determined the patient needs additional care, it is crucial that the provider obtains separate authorization — both to ensure reimbursement and to avoid out-of-pocket costs.
For emergency care, no prior authorization is needed, but providers must report emergency treatment to the VA within 72 hours. Numerous factors go into the VA’s decision whether an unauthorized claim should be paid, such as:
- Whether the treatment is for a service-related condition
- Whether the treatment is available at a nearby VA facility
- Whether the provider is part of a VA community care program
2. Lack of coordination when filing claims
In addition to keeping abreast with Veteran patients’ eligibility requirements for VA benefits, providers also need to be up to date with the VA’s requirements for submission and filing.
For authorized care, providers need to go through one of the following three routes, depending on your status in the VA’s network and how the care was authorized:
- Community Care Network (CCN)
Providers that are part of the CCN must file the claim with the correct third-party administrator — Optum United Health Care in Regions 1-3 and TriWest Healthcare Alliance in Regions 4-5 — as per the authorization/referral.
- Patient Centered-Community Care (PC3) Network
CCN has been rolling out in phases and will eventually replace PC3 entirely, but existing PC3 referrals still remain intact for some Regions and valid for the entire scope and length of the approved referral. Providers that provide care through PC3 should file claims with TriWest. Care through PC3 continues in CCN Regions 5 (Alaska) and 6 (Pacific Islands) through March 31, 2022.
- Veterans Care Agreement (VCA)/Local Contract
Providers that have a Veterans Care Agreement (VCA) established with VA or are not part of one of VA’s formal networks should file claims directly with VA.
When the care is authorized, providers must submit claims within 180 days. Although claims can be processed without supporting documentation, providers need to submit these documents to the referring VA facility as soon as possible to ensure the Veteran’s medical record is updated. The documents may be sent via HSRM, secure email, fax, or health information exchange system.
For unauthorized, emergency treatment, filing requirements depend on whether the condition is related to military service. Service-connected unauthorized emergent care must be billed within two years from the treatment date, while claims for non-service connected emergency treatment must be submitted within 90 days. Claims for unauthorized care require supporting documentation, which can be sent via electronic data interchange (EDI) or regular mail, although VA strongly encourages electronic submissions.
3. Lack of resources to follow up
Successfully adjudicating VA claims depends in large part on following up persistently through to resolution. Claims involving health insurance payers are typically recovered in one or two touchpoints, but VA reimbursement is a marathon, not a sprint, requiring a high-touch process by resources with specialized knowledge to navigate the VA’s complexities.
VA’s guidance that clean claims will be processed within 30 to 45 calendar days, for example, doesn’t always hold true. It’s not unusual for providers to wait on unpaid VA claims for up to a year — or more — severely impacting the bottom line as these claims snowball into millions of dollars in lost revenue.
Following up on VA claims is one of the most important steps to getting reimbursed, but few providers have the resources or time to do so efficiently. To check the claim processing and payment status, staff must first identify the correct route of the claim, then attempt to contact the right department via the right channel. However, stringent procedures within the VA make this a tedious task. With limited phone access hours, and a limited number of claims that can be discussed per call, staff may need to spend hours just to follow up on one claim.
Additionally, providers may need to send medical records and other required documentation multiple times — to both the VA contractor and the proper VA facility, which may be either the treating facility that referred the patient to your health system or the VA facility closest to the Veteran’s home.
4. Limited denials information
VA regulations differentiate a denied claim from a rejected claim. When a claim is “denied” it is because there is not a basis for a payment, but a claim may also be “rejected,” which means that it cannot be decided until the claimant provides additional or corrected information. An August 2019 nationwide audit estimated that 31% of denied or rejected non-VA emergency care claims were inappropriately processed, shifting the financial burden of care to the Veteran. As with other patients who are inadequately insured, this also presents a financial burden to the provider, absorbing millions of dollars in uncompensated care.
For providers, navigating the VA maze to obtain feedback on why a claim was denied or rejected — if the claim was appropriately processed in the first place — is an endless source of defeat that only contributes to higher processing costs. With VA claims making up 3-5% of total revenue, hospitals and health systems may find outsourcing to be a far more profitable and cost-effective solution.