Access Management & Care Coordination (AM & CC) Jason Chaddock, Chief Louis Stokes Cleveland VA Medical Center 10701 East Blvd. Cleveland, OH 44106 Northeast Ohio HFMA/AAHAM Conference February 16, 2017

AM & CC Section within Patient Care Administration Services (PCAS) designed to manage, coordinate and oversee Care in the Community (CITC) with clinical and administrative oversight. Responsible for CITC programs. CITC Consults Veterans Choice Choice-First Consults, Choice-Wait List Consults, Geoburden CITC Authorizations Provider Agreements

Pre-authorized Care – 38 USC 1703 CITC Process Provider enters request for Non-VA Care Request must be approved  Chief of Staff or designee AM & CC Staff coordinate care by working with Veteran and Vendor Authorization entered Medical information and authorization is faxed to vendor Appointment scheduled Medical records of appointment/care requested Episode of Non-VA Care is completed Vendor submits bill to Community Care Office for payment

Veterans Access, Choice, and Accountability Act of 2014 (VACAA). On August 7, 2014, the President and Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 ("Choice Act"). This act included a variety of ways to improve Veteran access to healthcare. The biggest change was the establishment of the Veterans Choice Program (per Section 101 of the new law). The Veterans Choice Program (VCP) created a new process for some Veterans to receive health care in their communities rather than waiting for a VA appointment or traveling to a far-away VA facility. Third Party Administrator – Northeast Ohio Health Net Federal Services https://hnfs.com/content/hnfs/home/va/provider.html

Veterans Choice - Eligibility Veteran must be enrolled in VA health care and meet at least one of the following criteria: You are told by your local VA medical facility that they will not be able to schedule an appointment for care either: Within 30 days of the date your provider determines you need to be seen; or Within 30 days of the date you wish to be seen if there is no specific date from your provider. Your current residence is more than 40 miles driving distance from the closest VA medical facility (including Community-Based Outpatient Clinics) that has a full-time primary care physician.” You need to travel by plane or boat to the VA medical facility closest to your home. You face an unusual or excessive burden in traveling to the closest VA medical facility based on geographic challenges, environmental factors, or a medical condition. Staff at your local VA medical facility will work with you to determine you are eligible for any of these reasons. Your specific health care needs, including the nature and frequency of the care needed, warrants participation in the program. Staff at your local VA medical facility will work with you to determine if you’re eligible for any of these reasons. You reside in a State or a United States Territory without a full-service VA medical facility that provides hospital care, emergency services, and surgical care having a surgical complexity of standard, and reside more than 20 miles from such a VA medical facility. NOTE: This criterion applies to Veterans residing in Alaska, Hawaii, New Hampshire, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands. Also note that some Veterans in New Hampshire reside within 20 miles of White River Junction VAMC.

Veterans Choice Veterans Choice Process Provider determines services/care is needed Service not provided, cannot schedule with appropriate timeframe, etc. AM & CC Staff contact Veteran to explain Veterans Choice Program Veteran must opt-in to participate in Veteran Choice Program Medical documentation and eligibility uploaded to Health Net Health Net coordinates with Veteran and Vendors within network Health Net provides authorization and medical documentation to vendor and works with vendor to schedule appointment Health Net responsible for retrieving medical records and providing to VA Vendor submits bill to Health Net for payment

What We Do The VA Care Team: The VA Care Team: CITC Consult is entered requesting service (once approved it can take one of 2 paths) What We Do Non VA Care Our team manages the entire consult from beginning to end Veterans Choice Program Our team manages the front and back end What does this mean? The VA Care Team: Ensures that all approval/eligibility/auths. are obtained Contact the Veteran/Vendors and coordinate/schedule the apt. Documents appropriately the scheduled appointment Continues to communicate with the Veteran with any ?s Assures all pertinent records are given to the provider/Veteran Follows up with the Vendors and obtains medical records Processes/documents pertinent information into CPRS Communicates with health care team regarding Veterans care Manages follow up appointments/records and continued care r/t the consult request – continued documentation. The VA Care Team: Ensures that all approval/eligibility/auths are obtained Calls the Veteran and explains the Choice program Uploads all necessary documents into the Choice Portal Continues to monitor portal for updates Requests updates as needed from portal Obtains medical records from portal Processes/documents pertinent information in CPRS Manages complaints, opt-outs, questions, escalation line

Provider Agreements Veterans Choice Program (VCP) Provider Agreements are one tool VA was authorized to use as part of the Veterans Access, Choice and Accountability Act of 2014 (VACAA). Approved Provider Agreements allow VA to partner directly with community providers when the VCP contractors are unable to provide services. The agreements utilize VACAA funds and require community providers to meet the same eligibility requirements as providers who furnish care through agreements with the contractors, however the VCP Provider Agreements are NOT contracts, they are just that – Provider Agreements.

Patient Transfer Center The Patient Transfer Center is responsible for managing Veterans in the community. Pre-Authorized Care and Emergency Care (38 USC 1703) Unauthorized Emergency Care (38 USC 1728 and 38 USC 1725) Vendors must contact the Patient Transfer Center to provide notification a Veteran is in your facility. Notification must be made within 72 hours of admission/treatment Veterans may be transferred to the VA, process starts with Patient Transfer Center Hours of operation Monday – Friday, 7:00am to midnight Saturday and Sunday, 7:00am to 4:00pm Telephone Number to call (216)791-3800 ext. 5596

Questions… Jason Chaddock Snjezana (Mary) Coyner, RN Chief, AM & CC Nurse Manager, AM & CC Patient Care Administrative Service Patient Care Administrative Service Louis Stokes Cleveland VA Medical Center Louis Stokes Cleveland VA Medical Center 10701 East Blvd. 10701 East Blvd. Cleveland, OH 44106 Cleveland, OH 44106 (216)791-2300 ext. 4102 (216)791-2300 ext. 4103 Health Net Federal Services 1 (866) 606-8198 Billing Address: Veterans Choice Program PO Box 2748, Virginia Beach, VA 23450

VISN10 Office of Community Care (OCC) Scott Walker, VISN 10 Manager Northeast Ohio HFMA/AAHAM Conference February 16, 2017 Note name change

VISN10 Office of Community Care What is Community Care? Community care (aka Fee, Fee Basis, Non-VA Care, or Purchased care) is a program that arranges or pays for medical services for Veterans outside a VA medical facility. Community Care is not an entitlement program, but a method of healthcare delivery for eligible Veterans when VA care is not available. Veterans should always seek care at a VA whenever possible. Does Community Care need to be approved in advance? Yes; to ensure that VA pays for such care, services should always be pre-authorized. There are, however, 2 instances when care may be paid for even if it is not pre-authorized; i.e. emergent care. Bullet 1 – emphasize that it is not an entitlement. Bullet 2 – it is really yes and no depending upon the type of care

VISN10 Office of Community Care Emergent Non-VA Care 38 U.S.C. 1728 - Un-authorized care is when a Veteran obtains care without pre-authorization for a service connected condition in an emergency. 38 U.S.C. 1725 (Millenium Bill) - Mill Bill care is when a Veteran obtains care without pre-authorization for a non-service connected condition in an emergency. _______________________________________________________ Under both instances, VA may pay for this type of care if it is clinically determined that VA facilities were not feasibly available and if Veterans meet a series of administrative & clinical eligibility criteria.

VISN10 Office of Community Care Un-authorized Care (38 U.S.C. 1728) To meet the administrative eligibility requirements, care or services must have been rendered to a Veteran for at least one of the following: An adjudicated service connected disability A non-service connected disability associated with and held to be aggravating a service connected disability For any disability of a Veteran rated permanently and totally disabled (P&T) due to a service connected disability For any illness, injury, or dental condition of a Veteran participating in the Chapter 31, Vocational Rehabilitation Program, for the reasons enumerated under 38 CFR 17.47(i) Firs focus on admin eligibility Bullet 1 and 2 - Link back in some way to the service connection

VISN10 Office of Community Care Un-authorized Care (38 U.S.C. 1728) (cont.) To meet the clinical eligibility requirements, the following criteria must also be met: When such care or services are rendered in a medical emergency of such a nature that a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health VA or other Federal facilities were not feasibly available to provide the needed care ________________________________________________________ Claims must be filed within 2 years after the date of service or discharge Clinical focus Will define prudent layperson in a couple of slides

VISN10 Office of Community Care Millennium Bill Emergent Care (38 U.S.C. 1725) To meet the administrative eligibility requirements, ALL of the following criteria must be met: Veteran is enrolled in the VA Health Care System Veteran has received health care services from the VA within a 24-month period preceding the emergency treatment (system auto-enrolls) Veteran has no other form of health insurance coverage Treatment was provided in a hospital, emergency room department, urgent care clinic, or a similar facility providing emergency care to public Veteran is financially liable for payment Veteran has no other contractual or legal recourse against a third party Administrative focus first. More stringent that 1728 unauthorized. Must meet all rather than just one.

VISN10 Office of Community Care Millennium Bill Emergent Care (38 U.S.C. 1725) (cont). To meet the clinical eligibility requirements, the following criteria must be also met: Care was rendered in a medical emergency of such a nature that a prudent layperson would have reasonably expected that delay in medical treatment would have been hazardous to life or health VA / Federal Facilities were not feasibly available at the time of the emergency event __________________________________________________________ Claims must be filed within 90 days after the date of discharge or date of death of Veteran

VISN10 Office of Community Care The prudent layperson definition of an emergency medical condition commonly in practice is any medical or behavioral condition of recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy. This prudent layperson definition of emergency medical condition focuses on the patient’s presenting symptoms rather than the final diagnosis when determining whether to pay emergency medical claims. Determined by the nurse reviewer

VISN10 Office of Community Care Claims Adjudication Process There are 2 methods to submit claims; electronically OR via snail mail. EDI Routing #12115 A processed claim is one that the Program Office has either, Approved for VA payment; Denied VA reimbursement; OR Rejected back to the non-VA provider Approved means the claim is the routed to the FSC in Austin, Texas for final payment. Denied – under 1725 or 1728 Reject – coding error, modifier error, revenue code issue, DOS outside auth date range

VISN10 Office of Community Care Customer Service (M-F, 10am to 2pm) Cleveland: 216-791-2300 x2003 Cincinnati: 513-475-6460 Dayton: 937-268-6511 x7677 Columbus: 614-257-5645 Chillicothe: 740-773-1141 x5550

VISN10 Office of Community Care Questions/Comments? http://www.nonvacare.va.gov/ Thank you.