4 unique challenges in Veterans Administration claims processing that lead to millions in lost revenue

Navigating Veterans Administration claims is a uniquely challenging and complicated process. Providers need to be keenly aware of these challenges to avoid writing off VA claims that snowball into millions of dollars of lost revenue.

VA insurance claims

By Kemberton | October 22 2021

The complexities of VA claims processing

The Veterans Health Administration is the largest integrated healthcare system in the U.S., serving over 9 million Veterans enrolled in the VA healthcare program. Although the VHA manages over 1,200 Healthcare Facilities, including 171 VA Medical Centers and 1,112 Outpatient Clinics, these facilities alone cannot handle the increasing volume of patients. Up to 6 million are actively receiving treatment, requiring more non-VA healthcare providers to treat a higher traffic of VA patients.

With the implementation of the MISSION Act of 2018 — intended to make it easier for Veterans to obtain care when and where they needed it — hospitals and health systems require a different approach in processing VA claims, which are overly complex and extremely time-consuming. Most healthcare providers’ patient financial services and revenue cycle teams are accustomed to collecting reimbursement from health payers, but, as providers know all too well, VA claims cannot be treated the same way as standard health insurance.

As the VA restructures to fulfill commitments made in the MISSION Act, and care programs subject to frequent change, navigating VA claims can be a daunting challenge for most healthcare providers. Without specialized resources equipped with the necessary expertise, VA claims can lead to higher proportions of aged A/R, low reimbursement, and millions of dollars written-off as underpayments — or even losses altogether. It’s a high complexity, low return component of the A/R largely without the right resources and training to tackle all of the red tape.

Some of the challenges in processing VA claims include:

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.

How Kemberton helps

Kemberton’s Veterans Administration Claims services remove the burden of VA claims collection from your revenue cycle team, leaving your in-house resources to focus on the traditional, more viable revenue cycle. With VA collections specialists and trained Veteran Advocates on staff, we provide a specialized and focused team with the knowledge and experience to comply with all of the VA’s complex filing requirements — working as an extension of your team to maximize reimbursement, reduce denials, and lower bad debt reserves on VA claims.

Contact us to learn how our specialized complex coverage expertise and personalized advocacy approach helps patients secure the coverage they need while delivering the financial reimbursements providers deserve.

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