VA gears up to take on Choice claims processing

VA gears up to take on Choice claims processing
Starting Oct. 1, the Veterans Affairs Department will step in to manage about 81,000 authorizations for the ongoing private-sector care of approximately 50,000 veterans in the VA Choice program.

Lawmakers and providers are watching how the VA handles the responsibility as the department is poised to take a larger role in processing claims thanks to the recently passed VA Mission Act.

Health Net Federal Services, one of two payers in charge of the private medical networks of the VA Choice program, lost its contract after community hospitals and physicians complained that they had to fight for adequate and timely payment. Its current contract is set to end Sept. 30.

The VA will serve as a stopgap after the contract expires, which could be a test run for its role in implementing the Mission Act—the major expansion of the Choice program passed by Congress in May and signed into law in June.

Skeptics are already questioning how the VA will fulfill its interim role. According to Health Net's latest updated transition plan, the contract-termination negotiations between the payer and the VA are ongoing. The majority of Health Net's responsibilities for care authorization processing and patient customer-service call centers have transitioned to the VA already.

But because Choice providers have 120 days to submit claims, Health Net will keep receiving claims up until March 26, 2019. There may be a window after this deadline for the company to pay any lingering reimbursements.

According to Health Net's transition plan, the VA will be taking an average of 6,500 daily calls from veterans, 2,400 daily calls from providers, and making 2,000 referrals per day and 34,000 care authorizations per month.

On the closely monitored payment issue, one congressional aide close to VA issues said it's still unclear whether the community providers in Health Net's region will see improvements in reimbursement speed.

"Providers should be watching, but they don't know how the Mission Act will look yet," the aide said. "Some could expect it to be totally different for the VA to have a role in paying claims, but I don't know if they know enough to have their antennas up."

Health Net and TriWest have been running point on managing the networks of private providers who take care of veterans under the VA Choice program. The two Health Net and TriWest regions roughly reflected an even geographic divide of the U.S. These two territories have now been split into four. The VA is expected to announce contracts for three regions by year-end and a contract for the fourth region in early 2019. Later in 2019, the VA will start implementing the Mission Act, which consolidates and expands all the community care programs for veterans.

Lawmakers hope the Mission Act will resolve the payment issues that have plagued providers in the VA Choice program. But the imminent end of the Health Net network has raised concern about how the VA will handle veteran referrals to private care in the short term. According to the congressional aide, the department is using provider agreements—including those from one-off visits to specialists—as a substitute for the network.

These agreements were supposed to operate as a stop-gap, the aide said.

"If there was a missing piece of the network, you could plug a hole with a provider agreement," the aide said. "But now there is no network, so they are using it to fill a huge gap until the Mission Act comes up."

The aide added that it still isn't clear what elements of claims processing and patient scheduling the department will manage in-house rather than contracting out, based on conversations with VA officials. For example, Congress assumed the department would manage appointment scheduling, but the VA indicated it may use a third party instead.

A bicameral, bipartisan briefing to all congressional committee staff on the VA's plans for the Mission Act was expected over August recess, but has been punted until after an upcoming VA Senate Committee hearing on the state of the department. This hearing is supposed to happen in September.

At least one lawmaker has publicly voiced concern about Health Net's contract termination and how it will affect veterans and providers in the Choice networks. In a Friday letter, the Senate VA Committee's Jon Tester (D-Mont.) asked VA Secretary Robert Wilkie about the VA's preparations.

"Given the chaos and frustration that veterans, community providers, and VA staff working with Health Net endured throughout much of the Choice Program, I cannot emphasize enough the importance of ensuring that this contract close-out process goes smoothly," Tester wrote. "Most importantly, there must be no disruptions in veterans' access to community care, and VA must ensure that community providers are promptly paid for delivering that care."

Tester also said he was concerned VA medical center officials may not have had enough time to hire enough staff to manage appointments and provide recruitment and claims processing.

Curtis Cashour, a VA spokesman, said the department will respond to Tester directly but noted the VA "is already performing most of the tasks for which Health Net had been responsible early in the Choice program's existence."

The VA will not hire new staff to manage the transition, but has provided specific guidance to VA medical centers in the Health Net areas "to ensure all veterans with existing episodes of care coordinated by Health Net are transitioned seamlessly."

Appointment scheduling and referral management will all be performed locally, the department said.

Roughly one-third of all medical appointments already happen outside of the Veterans Health Administration. About 640,000 new veterans are projected to move into community care annually in the early years of the program, according to a Congressional Budget Office analysis of the Mission Act.

The congressional aide noted that the VA has generally disappointed providers by paying them late. The Mission Act directed the department to look at the feasibility of contracting with third-party administrators to process community provider claims on behalf of the department. Congress is expecting that report shortly.