To prepare for good conversation, I remember my maternal grandfather, Papa Dziak, crossing his fingers over a pair of calloused palms and launching into anecdotes that brought him joy. One of his stories involved a Veterans Administration (“VA”) outpatient clinic. Papa Dziak served in World War II and traveled loyally to this facility for medical care. Apparently, the staff at this VA clinic called him on his birthday one year, telling him to swing by for a medical reason, but, when he arrived, he was instead presented with a full- fledged birthday celebration, complete with cake. Papa Dziak spoke highly of the clinic and its staff, and he was well-loved there. However, when he began experiencing stomach pain several years ago, the clinic could not provide him with either the appropriate examination or the necessary referrals for outside care. It was not until later, through his access to Medicare at a private medical center, that Papa Dziak was diagnosed with stomach cancer and provided medical attention.
Thankfully, Papa Dziak ultimately received some form of care for his illness, which is more than may be said for many veterans who suffer inexcusably long waiting times or substandard care from VA medical facilities. In 2014, whistleblowers released reports to CNN that VA hospital staff in Phoenix, Arizona, were fudging, and therefore hiding, appointment wait times. At the time, veterans were waiting anywhere from two to four months for VA hospital staff to schedule their appointments, an unacceptable fact that remained under the public radar until whistleblowers went to the press.Extensive wait times resulted in the death of dozens of veterans that could possibly have been prevented had the VA referred these veterans to outside providers.
This leak produced a cascade of reports from other VA medical facilities detailing disturbing inadequacies, and Congress quickly responded by passing the Veterans Access, Choice, and Accountability Act of 2014 (“Choice Act”).The Choice Act encouraged changes in VA structure and policy. One provision, in particular, charged the VA with expanding the “availability of hospital care and medical services for veterans through the use of agreements with non-Department of Veterans Affairs entities.” This provision gave rise to the Choice Program, which not only expanded already existing programs for out- side care but also provided veterans greater flexibility and more treatment options. Specifically, any healthcare provider “participating in the Medicare program[,] . . . [a]ny [f]ederally-qualified health center[,] . . . [t]he Department of Defense[,] . . . [and the] Indian Health Service” was eligible for a contract with the VA under the Choice Act, and the resulting extension of provider networks earned veterans larger pools in which to seek medical care. If any providers under these categories wished to participate in the program, they had to meet additional requirements, which included acceptance of Medicare rates and “compliance with all applicable federal and state regulatory requirements.” Third-party administrators assist the VA by establishing agreements with such non-VA providers once they meet all criteria. This includes negotiating rates for provided medical care and methods for timely reimbursement. The same third-party administrators are responsible for managing the contractual relationship between the VA and non-VA providers; related support services include scheduling appointments, manning call centers, overseeing medical services reporting, and coordinating care with private insurers.
Unfortunately, the VA has yet to fulfill its good intentions with the Choice Program, evidenced by the large number of veterans who continue to wait to see medical professionals or struggle to ensure that their claims are accurately processed once they finally have an appointment. The Government Accountability Office (“GAO”) reports that in FY 2015 and 2016, veterans referred to the Choice Program waited up to seventy calendar days for their appointments. Additionally, veterans relay personal experiences where either they were sent to the wrong non-VA health professional or they could not receive necessary treatment because the health professional was not yet authorized via Choice Program procedures. Aware of the persistent problems facing the VA healthcare system, and specifically those of the Choice Program, President Donald Trump signed the VA MISSION Act of 2018 into law on June 6, 2018. Among its provisions, the VA MISSION Act consolidated all Community Care programs — including the Choice Program — into one program known as the “Veterans Community Care Program.” The Veterans Community Care Program officially launched on June 6, 2019, implementing standards set forth in the VA MISSION Act and replacing the Choice Program.
For over half a century, the VA has utilized Community Care programs to provide care for veterans through non-VA-affiliated facilities, but their growing numbers only made them more difficult to administer. Consolidation brought all Community Care programs under one regulatory authority and meant that the VA must consider new contracts for third-party administrators to assist with implementation and operation. In preparation for these newly consolidated contracts, the VA decided to reclaim responsibilities that were previously left to third-party administrators, including appointment scheduling. The VA’s Request for Proposals for the contracts stated “that VAMCS — rather than [third-party administrators] — will carry out community care appointment scheduling.” This Note suggests that, instead of adding to its own responsibilities, the VA should entrust third-party administrators with scheduling and claims processing duties and additionally empower veterans to make their own decisions.
This Note argues that the VA should reform two Choice Program aspects that were consolidated into the Veterans Community Care Program: the process of scheduling veterans for appointments and the procedure for processing claims once appointments are scheduled. Veterans currently must rely on too many actors in a sequence of unnecessarily repetitive steps to schedule appointments. To make matters worse, the VA failed to adopt a system to accurately compare and track veteran wait times. The VA cites understaffing and authorization delays in response to the complaint that non-VA providers were not receiving timely compensation for their claims and thus could not afford to continue Choice Program participation. This is particularly troublesome at a time when the VA is increasingly referring veterans to outside providers because if those providers do not receive timely compensation, they gain little ability or incentive to renew their contracts. To effect meaningful change, the VA must adopt several new operative measures: the VA must streamline the methods for scheduling appointments, support veterans in scheduling their own appointments, contract out claims processing duties, and designate routine care for automatic authorizations.
Part II of the Note provides background on the origin of VA healthcare and preliminary Community Care programs, as well as the lead up to and implementation of the Choice Act. Part III of the Note describes the Choice Program scheduling and claims processing systems in detail and identifies specific flaws in both systems. Part IV presents solutions for scheduling under the consolidated Veterans Community Care Program, and Part V follows with suggested solutions for claims processing. Finally, Part VI concludes with the central theory that, if each presented solution is combined and incorporated, the VA would rightfully delegate much of its responsibility under the Veterans Community Care Program to selected contractors and individual veterans.
To better grasp the importance of seamless veteran access to non-VA provider healthcare options, one must understand the evolution of VA healthcare and how the Choice Act fits into the timeline. The Veterans Health Administration (“VHA”) is one of three subdivisions within the larger VA complex, the other two being the Veterans Benefits Administration and the National Cemetery Administration. It originated after President Abraham Lincoln, in the wake of the Civil War, called for the country to provide assistance for those who had laid their lives on the line for the country. From that point forward, VHA expanded dramatically, becoming one of the largest healthcare systems in the world; recent calculations place the VA health care system at “1,600 health care facilities . . . including 144 VA Medical Centers and 1,232 outpatient sites of care.” The VA Medical Center (“VAMC”) is the focal point of care offered through the VA, but that focus dims as more and more veterans return home from service overseas, seeking care that the VHA does not have either the capacity or the specialization to provide.
When an influx of military personnel arrived back in the United States after serving in World War II, the VHA recognized that it did not have the resources to provide so many service members with necessary care. VHA responded with a series of what they later coined “Community Care” programs. Community Care references programs implemented by VHA to provide and pay for veterans’ care through non-VA-affiliated facilities (i.e., private care providers). There are six Community Care programs that pre-existed the Choice Program, including individual authorizations for community care and Patient-Centered Community Care (“PC3”). Individual authorizations have served as the primary vehicle through which a veteran may reach outside the scope of VHA for medical services. VAMC staff will typically authorize such appointments if the specific service is either not offered at a VHA medical facility or if the veteran would have to travel an unreasonable distance to get to a VHA medical facility.
Officials at the VA began implementing a second form of Community Care in October 2013 called PC3 for purposes of “develop[ing] regional networks of community providers to deliver specialty care, mental health care, limited emergency care, and maternity and limited newborn care ” HealthNet Federal Services LLC and TriWest Healthcare Alliance Corporation, collectively referred to as third-party administrators (“TPAs”), were awarded contracts in September 2013 to administer the PC3 program and oversee network developments. Nearly one year later, PC3 expanded to include primary care providers in its available pool. Today, veterans are eligible to participate in PC3 if they are able to prove the same factors as those that appear in individual authorizations, including whether the service is not offered at a VHA medical facility or if the veteran would have to travel an unreasonable distance to get to a VHA medical facility.
Despite the availability of a number of Community Care initiatives, too many veterans remained subject to long waiting lists to receive the medical attention that they had earned. This led to the creation of the Choice Program.President Barack Obama signed the Choice Act into law on August 7, 2014, shuttling $10 billion towards the VA to expand veteran access to outside medical providers. One of several new initiatives during this time period, the Choice Program, cited specific criteria for veterans to meet before they were considered eligible for Choice. First, the “veteran must be enrolled in the VA health care system.” The VA accepts veterans’ submissions for healthcare enrollment on a rolling basis, and the VA decides whether to accept an application and which priority group the veteran falls under. These priority groups are subject to adjustment at the VA’s discretion, but usually the categories reflect the severity of assigned, service-connected disabilities and/ or income thresholds.
Once a veteran established enrollment, he or she must have satisfied one of four options to confirm access to the Choice Program: (1) “veteran attempts, or has attempted, to schedule an appointment with a VA health care provider, but VA is unable to schedule an appointment for the veteran within” certain wait-time goals; (2) “veteran’s residence is more than [forty] miles from the VA medical facility that is closest to the veteran’s residence;” (3) “veteran’s residence is both . . . [i]n a state without a VA medical facility that provides hospital care, emergency medical services, and surgical care having a surgical complexity of standard [and is] . . . [m]ore than [twenty] miles from [such] a medical facility;” or (4) “veteran’s residence is in a location . . . which is [forty] miles or less from a VA medical facility and the veteran . . . [m]ust travel by air, boat, or ferry to reach such a VA medical facility; or . . . [f]aces an unusual or excessive burden in traveling to such a VA medical facility based on geographical challenges, . . . environmental factors, . . . a medical condition[,] . . . or other factors, as determined by VA.”
Once a veteran was deemed eligible for Choice, instead of being referred, he or she had the option of selecting their own non-VA provider. This is an aspect of the Choice Program that provided veterans with some much-needed autonomy, as veterans were able to conduct their own research or select someone with whom they are already familiar. However, it is important to note that the VA will reimburse a non-VA provider only if the provider is covered by existing agreements with the VA or is an eligible entity by standards set forth under the Choice Act and 38 C.F.R. § 17.1530. In other words, a non-VA provider must be authorized by the VA before receiving payment for the care provided to a veteran enrolled in any Community Care program. Originally as mandated under the Obama Administration, once non-VA care was authorized, the Choice Program designated the VA as a secondary payer, meaning that the first bill would go to a veteran’s other healthcare sources, and then the VA would cover the rest. However, in April of 2017, President Donald Trump signed off on a change to this standard, requiring the VA to take on primary payer status for all non-service-related disabilities. Thus, the VA now receives the first bill for not only service-connected conditions but also non-service-connected conditions.
Due to requirements under the Choice Program for larger provider networks and the growing need of veterans for non-VA medical attention, the VA expanded its pre-existing contracts with TPAs, HealthNet and TriWest, both of which had already established networks of providers through the PC3 program. Expanded TPA responsibilities under the Choice Program included scheduling appointments for veterans with non-VA providers, developing non-VA provider networks, and assisting the VA with processing claims for payment to non-VA providers. In their respective regions, HealthNet and TriWest worked at these duties for approximately four years, until HealthNet’s contract with the VA ended in September 2018. On October 2, 2018, the VA granted a one-year extension on TriWest’s already existing contract and announced that TriWest would take over all HealthNet regions.
The decision to expand and extend the TriWest contract came after Congress passed the VA Budget and Choice Improvement Act in July 2015, which mandated that the VA consolidate all of its Community Care programs, including the Choice Program, into one program to be called the Veterans Choice Program. In response to this mandate, the VA sent out a Request for Proposals in December 2016 for new “community care network” (“CCN”) contracts to assist with the implementation and administration of the consolidated program. After a change in presidential administration and the signing of the VA MISSION Act of 2018, the name changed from the Veterans Choice Program to the Veterans Community Care Program. Though the title changed, the Veterans Community Care Program seeks the same consolidation, and the VA is currently in the course of awarding CCN contracts to new TPAs. The purpose of adjusting contractual obligations between Tri-West and the VA is not only to ensure smooth transition pending full Veterans Community Care Program implementation, but also guarantee that veterans continue to receive timely care. However there is significant controversy surrounding whether veterans are actually receiving the timely care intentioned by the Choice Act. To remedy this, the CCN contracts should include streamlined scheduling procedures, support veteran autonomy in scheduling, and emphasize efficiency and expediency in claims processing.
Before the VA modifies contracts with third-party administrators who will effectively execute and manage the Veterans Community Care Program, the agency must reform the scheduling and claims processing systems. To understand the implications of proposed solutions, one must first understand how the systems operated under the Choice Program and how problems have developed over the course of their existence.
Under the CCN contracts, the VA must decide how scheduling under the Veterans Community Care Program will be reformed. There were two separate processes: these depended on whether a veteran was eligible for Choice because of long wait times or because of unreasonable distance. For time-eligible veterans, the process began when a VHA clinician confirmed that a veteran in need qualified for Choice and contacted the veteran to see if they would like to be referred to the Choice Program. Once a veteran confirmed, VAMC personnel compiled all pertinent medical records to send in a referral to the TPA. The TPA reviewed the referral and “accept[ed] the referral if the information [was] sufficient;” after this step, even though the veteran had already confirmed with the VHA clinician that they wanted a Choice referral, the TPA attempted to contact and confirm with the veteran a second time before fully authorizing care. After they received affirmation from the veteran, the TPA proceeded to schedule an appointment with a non-VA provider who received the TPA authorization containing “relevant clinical information, a description of authorized services, and a period of validity.”
The key difference in the process for distance-eligible veterans was that the veterans directly contacted the TPA without waiting for a referral from VHA, and it was the job of the TPA to confirm veteran eligibility. Distance-eligible veterans represent the minority of cases, however, because, in FY 2015 and 2016, approximately ninety percent of veterans utilizing Choice were referred because they were time-eligible. Though intended to open and ease veteran access to timely medical care, the complexities in the differing scheduling processes ran into problems, as reflected in recorded data as well as veteran anecdotal experience.
One veteran in particular, Mr. Irvin Bishop Small, was referred by his VA doctor to the Choice Program, but after receiving only a phone number to call, Mr. Small waited weeks for the Choice Program to respond. For ten years, Mr. Small carried “heavy gear up and down ladders” while serving in the U.S. Navy, and as a result he experiences severe pain in his knees and ankles. Sometimes the pain is so severe that his feet go numb, and it starts “to feel like somebody’s wrapping a molten metal band around [his ankles].” The closest VA medical facility is over forty miles from his home, making Mr. Small a distance-eligible veteran under the Choice Program; thus, after his VA doctor prescribed acupuncture and physical therapy in December 2015, Mr. Small called Choice. Mr. Small attempted to make contact with the Choice Program for several weeks, after which Choice finally attempted to schedule him an appointment with three different clinics. All of these clinics could not offer Mr. Small the care he sought. Eventually, Mr. Small received acupuncture and physical therapy to relieve the pain in his lower limbs, but only after a grueling series of events and well beyond the thirty-day wait-time goal established by the VA.
Despite the fact that the Choice Act was promulgated in part to eliminate such extensive waiting times at VHA, the averages appeared no better under Choice. In FY 2015 and 2016, approximately ninety percent of all veterans referred to the Choice Program were time-eligible veterans and were thus referred because they could not be scheduled for an appointment with the VA within thirty days. Ironically, these veterans waited up to seventy calendar days for their appointments due to much shuffling around between VA and TPA responsibilities. The scheduling process for time-eligible veterans began when a VA medical provider flagged a veteran in need of care, and, from that moment, VA staff had four calendar days to initiate contact with the veteran to offer a Choice referral. Once contact was first attempted, VA staff had fourteen days to successfully contact a veteran to confirm that the veteran wanted to utilize Choice. From there, VA staff submitted a referral to the TPA that then had sixteen business days or twenty-two calendar days to review the referral and contact a veteran for a second-round confirmation. Once the TPA received confirmation from the veteran and the TPA created the subsequent authorization, the TPA had thirty calendar days from authorization to schedule an appointment with a non-VA provider. Eighteen total days is all that is currently attributable to the VA in the grand scheme of scheduling delays comparable to the remaining fifty-two that are left to the TPAs. However, a glaring hole exists in the data, and that is the time it took for a VAMC to collect a veteran’s relevant medical information and submit their referral to the TPA.
The reason why VHA was unable to systematically track the time it took for VAMC staff to submit referrals is because there was no standardized categorization for consults in the VA’s electronic health record. A consult was entered into a veteran’s electronic health record when a VHA clinician requested “an opinion, advice, or expertise regarding evaluation or management of a veteran’s condition.” Should the veteran be referred to the Choice Program to gain this “opinion, advice, or expertise” from a non-VA provider, VAMC staff “use[d] information from the consult — such as the clinically indicated date determined by the VHA clinician and a description of needed services — to prepare veterans’ Choice Program referrals.” Since the consult titles were not the same across the board, VHA could not automatically pull data from their electronic system to successfully calculate average wait times. Remedying this problem is only the first step in ensuring that VHA accurately identifies scheduling delays.
A possibly more glaring problem is that VAMC staff inappropriately changed the clinically indicated dates included on referrals. In a GAO sampling involving 196 Choice referrals, GAO identified 134 referrals with clinically indicated dates, and in 60 of those 134 referrals, the clinically indicated date was different than the date originally entered by the VHA clinician. The VA used the clinically indicated date, in part, to calculate its thirty-day wait- time goal. By adjusting this date on the referral, VAMC staff manipulated “veterans’ wait times [to] appear . . . shorter than they actually were.” Considering that the VA lacks the oversight necessary to prevent falsified wait- time reports, allocating scheduling responsibilities to the agency may not be the wisest option under the Veterans Community Care Program.
In addition to analyzing the scheduling process under the new Veterans Community Care Program, the VA should reconstruct the system for claims processing. According to a January 2010 VHA directive, ninety percent of all claims submitted from Community Care programs must be processed within thirty days of receipt. Data from FY 2015 show that VHA successfully processed only sixty-six percent of all claims within this mandated timeframe. Furthermore, GAO asserted that “VHA’s data likely overstate its performance because they do not account for delays in scanning paper claims.” Comparatively, the Department of Defense (“DoD”) maintains a healthcare system called TRICARE and mandates that ninety-eight percent of all TRICARE claims must be processed for payment within thirty days of receipt. In a system that services approximately “9.6 million military service members, retirees, and dependents and survivors,” compared to VHA’s 9.1 million veterans, TRICARE processed ninety-nine percent of claims in thirty days or less in FY 2015. An exploration of the similarities and differences between the VHA and TRICARE processing systems reveals implementations that VHA should utilize as they construct the CCN contracts.
Under “individually authorized care” and all other Community Care programs that are not PC3 or Veterans Choice, the non-VA provider submits a claim to a VHA processing location once the veteran receives care. Conversely, under PC3 and Veterans Choice, non-VA providers submitted claims to the TPA where the claim was initially processed and the non-VA provider was appropriately paid, and then the TPA submitted the claim to the same VHA processing facilities for reimbursement. Staff at VHA processing locations used a Fee Basis Claims System (“FBCS”) for all claims submitted through any of the VA’s Community Care programs, and non-VA providers were required to include supporting medical documentation with most claim submissions. If medical documentation was included with the claim, everything must have been submitted in paper format, which the VHA staff then date-stamped and manually scanned into FBCS. Once all hardcopies were scanned, VHA staff compared the hardcopy and electronic version of the claim side by side to assess whether the system captured data accurately, after which the claim got sent up the chain to VHA staff with particular processing expertise. At this level, FBCS did not have the capability to “automatically apply relevant criteria and determine whether claims are eligible for payment.” Instead, VHA staff had to go through the claim line by line to verify if the claim met criteria qualifying payment and then provide adequate bases for their reasoning. After the VHA processing staff concluded the assessment process, and, depending upon the Community Care program that originated the claim, VA financial services routed payment to either a TPA for reimbursement or directly to a non-VA provider.
Claims processing under TRICARE is similar to that of VHA in many ways, including that staff must manually compare hardcopy and electronic versions of scanned materials to verify that data is captured correctly. However, there are several notable differences. First, the DoD contracts out the responsibility for all TRICARE claims processing to TPAs. Second, TRICARE “only requires prior authorization for specialty care services,” as opposed to VHA which requires that all care rendered by Community Care programs be authorized before a veteran may receive care and before the non-VA provider will receive payment for the care. These are particularly important differences between the TRICARE and Choice Act/ Community Care programs because VHA alleges that administrative problems and authorization delays cause inadequacies in its claim processing. Unlike TRICARE, VHA claims processing cannot continue as-is under the new Veterans Community Care Program because it results in egregious delays in payment to non-VA providers and places barriers between veterans and the care they deserve.
A large medical institution may be equipped to continue veteran care for several years without proper compensation from the VA, but the issue of late or complete lack of payment presents a much larger problem for smaller private-practice doctors who may not have the resources or manpower to function without support. Mental health specialists are in high demand in VA medical facilities, and non-VA private practice providers who are aware of this — such as clinical psychiatrist Dr. Morrow-Bradley — chose to participate in the Choice Program to assist the overwhelming number of veterans who require mental health attention. After Dr. Cher Morrow-Bradley was certified through HealthNet as a Veterans Choice provider, however, it took her almost a year to fight for the several thousands of dollars owed to her by the VA. Luckily, Dr. Morrow-Bradley believes that her veteran patients require consistent attention and continues to treat them despite delays in VA payment, but this may not be possible for other private mental health specialists.
In addition to their battle with late payments, private practice doctors struggled with the Choice Program authorization process, which either required several separate authorizations for repetitive treatment plans or did not authorize certain treatment plans at all. For example, if Dr. Morrow-Bradley wanted to schedule a veteran for two sessions a week, she was required to seek new authorizations every month, and, should that veteran require more than basic therapy coverage, the VA would not authorize the therapy for reimbursement. This is extraordinarily counterintuitive and counterproductive because mental health treatment often requires regular office visits and the nation’s veterans often need more than basic therapy for debilitating post-traumatic stress symptoms. If the VA wants to provide the best available treatment to veterans, including innovative psychological therapies, the agency must overhaul the Veterans Community Care Program’s system for processing claims.
As the VA consolidates all Community Care programs, the agency needs to revisit the routine in place for scheduling non-VA provider appointments because veterans are still facing delays when seeking outside care. In addition, the VA is not accurately tracking timeliness data related to scheduling to gauge whether veterans are alleviated from long VA wait times or excessive distance by their ability to receive outside care under Community Care programs. In a system with many moving parts and different processes for time-eligible versus distance-eligible veterans, it is easy for a veteran to get lost. If the VA is not equipped to truthfully assess where problems can be fixed, veterans will continue to wait.
Specifically, the VA cannot assign TPAs the blame for unacceptable performance in Community Care programs when they lack the data-tracking methods and oversight procedures to ensure that its part of the bargain is upheld. Faced with veteran complaints that appointments were not being scheduled in a timely manner, the VA in Alaska and North Dakota decided to reclaim the task of scheduling Choice Program appointments in 2016. At the Alaska VA Health Care System and the Fargo VA Health Care System, VAMC staff ran pilot programs in which TPAs were only sent clinical information after the VAMC had already scheduled veterans for appointments. These pilot programs are especially important because the VA’s Request for Proposals for the CCN contracts stated that “VAMCs — rather than TPAs — will carry out community care appointment scheduling, unless VA exercises a contract option for the TPAs to provide such services” Ironically, though the VA seemed to think that exercising more control within the Choice system would solve its problems, the agency has not evaluated the effectiveness of the pilot programs to gauge whether VAMCs scheduled “appointments in a more timely manner than TPA staff.” Considering that the VA fails to accurately track veteran wait times and lacks oversight procedures, it does not seem to be a thoroughly justified decision to allocate scheduling tasks based on speculative pilots.
Instead of disseminating the Alaska-inspired trial run to all of the nation’s veterans, the VA should consider streamlining scheduling procedures by removing unnecessary steps. To improve the timeliness of scheduling veterans under new CCN contracts, the VA should first mandate that all eligible veterans under the Veterans Community Care Program must go through the same procedure so that all parties involved are not confusing responsibilities. This mandated procedure should follow the general flow of the procedure for time-eligible veterans under the initial Choice Program. (Recall that in FY 2015 and 2016, the vast majority of veterans referred to the Choice Program were time-eligible veterans.) Exactly as the process for time-eligible veterans began, any veteran eligible under the consolidated Veterans Community Care Program must have a referral from VAMC staff. Once VAMC staff identifies a veteran who is eligible and confirms with the veteran in person or via telephone that he or she would like to participate in the Veterans Com- munity Care Program, VAMC staff should immediately connect the veteran to an in-house member of the TPA team. For example, if Papa Dziak had an appointment with a practitioner at a VHA facility who prescribed him a certain test for his stomach pain, Papa Dziak should be able to walk out of the examination and into the reception room where staff confirms whether he is eligible for the Veterans Community Care Program. If he is eligible and chooses to go outside the VA for his prescribed test, then he should be able to consult with a member of the TPA team that very same day at that very same VHA facility. By striving to create a single continuous line of communication between the veteran, VAMC staff, and TPA staff, the VA would cut down the current time it takes for VAMC staff to contact veterans and for the TPA to perform repetitious confirmations.
Second, the Veterans Community Care Program should grant veterans the autonomy to schedule their own appointments with TPA-verified, non-VA providers. After VAMC staff refer a veteran to the Veterans Community Care Program, TPA staff should have a conversation with the veteran about viable options in the TPA network of non-providers, and then provide the veteran with the proper contact information, unless the veteran elects to have the TPA schedule an appointment with the non-provider for them. For example, after the VHA practitioner requests a specific test for Papa Dziak that may be fulfilled through the Veterans Community Care Program, the order is handed over to TPA staff. TPA staff examine the established network of non-VA providers and have a conversation with Papa Dziak about the providers available to him. If Papa Dziak wants to schedule his own appointment, he is given appropriate contact information and his referral from the VA, and the TPA then tracks through the selected provider when that appointment is scheduled and completed.
A cause for some concern may involve whether or not VAMC staff will be able to supply a veteran’s health records in time before the non-VA provider appointment is scheduled. The answer to this is that each non-VA provider will know when certain health records are necessary and when they are not and are equipped to schedule with veterans accordingly. Sometimes non-VA providers may not require any prior medical records to proceed with medical testing or treatment, and if they do require certain medical information, they can detail to the veteran why they may need to take a quick pause in scheduling. This is the beauty in veterans having direct links to their non-VA providers for scheduling instead of having to go back and forth with TPA or VAMC staff about why appointments are not happening. Furthermore, to improve the expediency with which VAMC staff submit referrals and supply health records, VHA should create a fast-track for episodes of routine care. Routine care may include annual physicals, maternity care, and optometry visits that translate down the line to claim processing.
It is imperative that VHA presents feasible solutions within CCN contracts for current administrative staffing and authorization problems with veteran claims processing. If not, non-VA providers will continue to be disincentivized from participating in the Veterans Community Care Program, making it harder for veterans to acquire timely, suitable care. One example of this is detailed in a statement made by Vince Leist, President and CEO of North Arkansas Regional Medical Center, to the Committee on Veterans’ Affairs of the U.S. House of Representatives. In the June 2015 hearing, Mr. Leist stated that the North Arkansas Regional Medical Center would no longer contract with the VA “due to slow or no payment for claims and the bureaucracy involved in getting reimbursement for claims.” At the time, the VA owed North Arkansas Regional Medical Center $750,000 for 215 pending claims. This is one example amongst many, and other non-VA facilities with large veteran-client bases are owed even greater amounts from the VA, some as much as tens of millions of dollars. If the VA is to provide the most comprehensively effective care for veterans, the agency must address administrative and authorization problems in the claims processing system that deterred non-VA healthcare providers from participating in Choice.
Speaking to the administrative burden, VHA claims that staffing shortages are partially responsible for claim processing delays. From FY 2012 through FY 2015, the number of claims processed by VHA staff increased dramatically from approximately 9.3 million to 16.9 million, but the number of processing staff positions did not increase to match, leading “to poor staff morale, attrition, and staff shortages.” However, upwards of 2,000 people in ninety-five different locations are responsible for processing VHA claims compared to 650 people in three different locations who are responsible for processing TRICARE claims. These 650 people processed 55.7 million claims in FY 2014 compared to VHA’s 13.3 million. Instead of hiring more and more VHA staff, and expecting new staff to take on an arsenal of additional responsibilities including customer service, the VA should contract out all claims processing like DoD does with TRICARE.
If the VA were to include claims processing responsibilities in the Veterans Community Care Program contracts, this would lessen the administrative burden on VHA staff and allow VHA to concentrate either on elevating the agency’s level of medical care for veterans (e.g., recruiting much-needed medical health specialists) or supplying prompt authorizations if a veteran needs non-VA care. Like the previous TPA contracts under Choice, the contractors should be responsible for establishing networks of non-VA providers and should thus be familiar with the contracts between the VA and non-VA providers. With this familiarity, the contractors will be able to analyze submitted claims line-by-line to see if they meet criteria qualifying payment and should be equipped to provide customer service for the non-VA providers who submit the claims. By relinquishing these responsibilities to contractors who already understand and utilize efficient methods for processing, similar to those with TRICARE contracts, the VA will quicken claim turnover and thus enable timely payment to non-VA providers.
Speaking to authorization problems, VHA asserts that claims processing and payment to non-VA providers is sometimes delayed because authorization is not always available in FBCS. This seems counterintuitive considering that before a veteran is even able to schedule an appointment with a non-VA provider, he or she must gain authorization. As noted above, VAMC medical personnel must confirm in a veteran’s electronic health record that the veteran is eligible for non-VA care, and the TPA must also complete authorization procedures prior to scheduling appointments. However, according to VHA staff, the veteran’s electronic health record is separate from FBCS, and once VAMC medical personnel confirms a non-VA referral in the electronic health record, they must then create a separate authorization in FBCS. If the authorization is not available in FBCS when the time comes for the claim to be processed, then processing is delayed until either VAMC releases the authorization or creates an entirely new authorization. This further exacerbates the problem of perpetually pending payments to non-VA providers, causing them hesitation when deciding whether or not to contract with VA.
To help curb suspension of claim authorization at processing time, the VA should adopt two new policies when implementing the Veterans Community Care Program. First, VHA should designate types of routine care eligible for automatic authorization, and second, upon contracting out claim processing responsibilities, VHA should no longer be responsible for creating separate authorizations for FBCS. A key difference between TRICARE claims processing and current VHA claims processing is that TRICARE only requires authorization for “specialty care services.” While it may not be feasible for VHA to narrow the field to the same degree, establishing prior authorization for routine care (e.g., annual physicals, maternity care, or optometry) will make processing more efficient because not only will it save time processing routine care claims, but also the contractors will be able to focus on processing more time-sensitive, specialized care for veterans. Additionally, for veterans who require regularly scheduled appointments, such as the patients seen by clinical psychiatrist Dr. Morrow-Bradley, the VA should set up a system authorizing longer-term treatment plans with options for renewal as needed. This way a veteran with mental health ailments who requires prolonged attention will receive care without having to struggle with non-VA providers over repetitive authorizations and resulting payment problems.
If the CCN contracts for the Veterans Community Care Program assign claims processing responsibilities to TPAs, veterans will not have to wait for VAMC medical personnel to create an authorization in FBCS because no FBCS will exist. The only authorization for which the VA should be responsible is the one that accompanies the veteran’s electronic health record prior to scheduling. Under this model, once veterans are initially referred to the Veterans Community Care Program and authorized by VAMC, the TPA that is contracted for claims processing moves forward with its own system with- out having to wait for any go signal from VA. All throughout the Choice Pro- gram, there were such points as these where veterans and non-VA providers waited for VA work product or decision, impeding the essential mission of the Choice framework to provide veterans with timely care. With the elimination of VAMC’s role in authorizing claims for FBCS, one potential waiting period disappears, and the efficiency of claims processing increases.
There are two large and important pieces of the Veterans Community Care Program equation: one fits at the very beginning (the scheduling phase) and one fits at the very end (the claims processing phase). Unfortunately, the Choice Program equation was not computing correctly as veterans still waited in long lines to receive the healthcare they deserve. In the process of consolidating all Community Care programs into one Veterans Community Care Program and seeking new contractors to fulfill new roles as TPAs, the VA must revisit both the scheduling and claims processing phases of the program and adopt policies that will help to remedy ongoing problems. With regards to scheduling, the VA should first streamline the process by removing unnecessary steps where too many actors are involved. Second, the VA should promote veterans scheduling their own appointments with TPA-contracted, non-VA providers. With regards to claims processing, the VA should first con- tract out all claims processing to TPAs, which eliminates the necessity for separate FBCS authorizations from VHA. Second, the VA should establish expedited authorization for episodes of routine care.
Perpetually shuffling around responsibilities is not the answer to fixing an already confusing system because it will only serve to produce more confusion. The VA should not be so quick to assign blame to those with whom it contracts when there is little data to assess what is happening from inside the agency. To repair elements of the Choice Program’s faulty design, the VA insists on adding to its own responsibilities by reclaiming appointment scheduling and hiring more VA staff to claim processing divisions. The agency should be moving in the opposite direction. Alternatively, the agency should take several steps back and not only allow TPAs to perform the jobs entrusted to them, but also allow veterans a voice in their own healthcare. Papa Dziak should be able to exit the examination room at a VHA facility, immediately understand whether he is eligible under the Veterans Community Care Program, and leave with resources to contact for medical care outside of the VA. He should be able to set up an appointment at a private office, with the necessary pieces of his health record, and leave the appointment knowing that a TPA is swiftly processing his claim without waiting for VA authorization.
If the suggested elements were incorporated into the Veterans Community Care Program equation, the only responsibility claimed by the VA would be confirming veteran eligibility and supplying initial referrals to in-house TPA staff. As a result, VHA clinicians and staff would be able to focus even more on the quality of medical attention that the agency provides to veterans within VA Medical Centers as well as outpatient facilities. Designating a new arena for CCN contracts is therefore imperative, and the VA must invest and trust in a competitive selection process so that TPAs are equipped to concentrate on the establishment and growth of strong non-VA provider networks and the timeliness of claim processing. This will heighten the availability and quality of medical care and treatment for men and women who have chosen to serve and protect the United States. Well over a century ago, President Lincoln called for the United States to provide such assistance, and the Veterans Health Administration quickly answered, but, today, the agency must remain attentive so that the assistance persists and the answer rings clear.
