VHA Office of Community Care (OCC) Announcements Digest - March 2018

VHA Office of Community Care (OCC)
Announcements Digest - March 2018

Note: This issue of OCC Announcements Digest includes messages released in February and January 2018.

Audit Contract for Recovery of Community Care Overpayments

As part of Federal efforts to reduce the number and amount of overpayments, VA is required by law (38 U.S.C. 1703) to award a contract to audit VA community care claims and payments and to initiate the recovery of any overpayments. The current recovery audit contract was awarded to CGI Federal, Inc., and includes claims paid from FY2013-2017.

As part of the contract, CGI performs the audit work, receives a percentage of the recovered funds, and the remaining amount is allocated back to the original authorizing VA medical facility to support care and services for Veterans. More than 90% of the recovered funds gets returned back to the VA medical facility and, to date, over $10 million has been returned to VAMCs through this process.

Audit Process

The audit process consists of several steps during which CGI will review claims data, flag potential overpayments, work to retrieve funds, and recovered funds are returned to VA. Specific steps are outlined below:

1. VHA Office of Community Care (OCC) provides claims data to CGI for their review.
2. CGI analyzes the claims and flags potential overpayments. CGI requests additional information from OCC on the flagged claims to validate the overpayments.
3. Once the overpayments are validated, CGI sends letters to providers to identify the amount of the overpayment and provide instructions for the provider to refund the money.
4. Recovered funds are sent back to OCC’s Financial Management Office for allocation back to the authorizing VA medical facility.
5. A percentage of the recovered funds is also sent to CGI.

Frequently Asked Questions

1. What types of claims will CGI be reviewing as part of this audit?

CGI will review all claims paid under 38 U.S.C. 1703 from FY2013-2017, with a few exceptions. Care purchased under a contract and claims paid outside of the Fee-Basis Claims System (FBCS) are generally excluded.

2. Why has CGI issued so many findings letters related to physician-injectable drugs?

In June 2017, a VA OIG report concluded that VA should have been paying physician-injectable drugs, commonly referred to as “J-codes,” at Medicare rates, rather than billed charges, since February 2011. OIG recommended that VA recover overpayments and VA concurred with these recommendations. In response, OCC has asked CGI to prioritize J-code reviews.

3. What happens if a provider receives a letter for a claim they have already refunded back to the VA?

The provider should contact the call center listed in CGI’s findings letter, (888) 309-8058. Generally, the provider can submit a copy of the check showing that the overpayment was refunded already, and CGI will cancel the case.

4. What happens if a provider disagrees with CGI’s audit results?

CGI provides instructions for requesting reconsideration in the findings letters. Providers are always welcome to request reconsideration of an audit finding.

5. I thought VA conducted internal audits over VA Community Care payments. Why is the recovery audit contract necessary?

VA is required by law to conduct a recovery audit by contract. Our internal audits typically review statistically relevant samples of claims. The recovery audit, on the other hand, is a 100% review. The recovery audit benefits VA medical facilities by returning overpaid funds to be used to provide further care for Veterans.

6. What happens if a provider disagrees with CGI’s audit results?

CGI provides instructions for requesting reconsideration in the findings letters. Providers are always welcome to request reconsideration of an audit finding.

7. I thought VA conducted internal audits over VA Community Care payments. Why is the recovery audit contract necessary?

VA is required by law to conduct a recovery audit by contract. Our internal audits typically review statistically relevant samples of claims. The recovery audit, on the other hand, is a 100% review. The recovery audit benefits VA medical facilities by returning overpaid funds to be used to provide further care for Veterans.

Support

• Questions? Please contact Travis Tougaw at Travis.Tougaw2@va.gov or 303-370-1649.

Community Care National CAC/Non-Count Clinic Menu Build for Community Care Colorectal Cancer Screening/Surveillance-Clinical

The VHA Office of Community Care is working collaboratively with the National Colorectal Cancer Screening / Surveillance (CRCS/S) Workgroup on the implementation of the new CRCS/S clinical reminder. In order for the clinical reminder to work as intended, facilities must implement Community Care consults and consult note titles.

A 10N memo was released for mandatory implementation of the New National Colon Cancer Screening-Surveillance (CRS/S) Clinical Reminders across all VHA facilities. The new national reminder system replaces all existing colon cancer clinical reminders currently in use across VHA. Full implementation and monitoring of the reminder system will improve timely care for the Veteran and allow facilities to identify gaps in the care continuum. Use of the Standardized Community Care Consults, Consult Result Notes and Non-Count Clinical are part of the requirement and effort when the Veteran will obtain care in the community. For information regarding the CRCS/S CR, please visit the National CRCS/S CR SharePoint. Note: See message from Office of Community Care Communications on February 23, 2018 to view a PDF version of the 10N memo.

The VA Medical Center Clinical Application Coordinators (CACs), and those who build Non-Count Clinics at their VA facilities, should complete the following three actions by Monday, March 5th, 2018.

Click this link for HI/CAC Information: Colorectal Cancer Tech Guide and Consult Templates.

Actions Required

1. Create four Community Care Colorectal consults and four Community Care Consult Result note titles. The consult service name must match the consult note title.

2. Create new Standardized Community Care Clinics for each of the 4 Community Colorectal Consults above. The Primary stop code for all COMMUNITY CARE clinics must be 669 and the Credit Stop code (secondary specialty stop code) should be assigned per DSS Identifier standards. The clinics must be designated as NON COUNT. 

3. Send an email to Kimberly.Spurlock@va.gov verifying that your site has completed action items 1 - 2.

Support

The following provide guidance on how to accomplish the ACTIONS above:

• Colorectal Cancer Tech Guide and Consult Templates
• Non-VA Colonoscopy V6.2 txml
• Non-VA Generic V6.2 txml

For technical questions regarding Community Care-Colorectal Consults and Community Care Consult Results Note, please contact Rick Woods, RN at Garold.Woods@va.gov.

For information regarding the CRCS/S CR, please visit the National CRCS/S CR SharePoint or for questions/concerns, please send an email to CRCS/S Clinical Reminder Implementation mail group—VHA CRCS CR Imp vacocrcscr@va.gov.

Infertility Treatment Options Available to Veterans

OCC needs your help in raising awareness of infertility treatment options available to Veterans and their spouses. These options include IVF treatment, which is now available due to a regulation change.

To help us spread the word, please share our new video entitled "Service-Connected Infertility Treatment," which explains eligibility requirements, treatment offerings, and how Veterans interested in treatment can schedule an evaluation. The video also encourages Reproductive Endocrinology and Infertility (REI) providers in the community to partner with VA to provide this care to Veterans. The video is available publicly on YouTube. Sample social media posts and a downloadable video file are located here.

 Visit the IVF Treatment webpage to learn more about available service-connected infertility treatment options.

National Deployment of Consult Toolbox Version 1.7.01

2. Version 1.7.01 of Consult Toolbox is now deploying nationally and must be in by April 23, 2018. After this date, we will track adoption of the software via use of the mandatory data elements and notify VAMC directors not in compliance.

3. To use Version 1.7.01 of Consult Toolbox for the first time upon installation, users must open CPRS, select “Consult Toolbox” from the “Tools” Menu, and select “Enable Consult Toolbox”.

4. Training is highly recommended for all staff using Consult Toolbox, and is available through two modalities on the VHA Community Care Solutions site:

• Office Hours Support, which will be hosted every Wednesday at 2:00 PM EST.
• Consult Toolbox Version 1.7.01 training describes the functionality of the Consult Toolbox.

5. Additional Consult Toolbox resources for VA staff include the following:

• Consult Toolbox User Guide
• Consult Toolbox Report. Access to this Report is available by requesting access to Protected Health Information/Personally Identifiable Information data from the Corporate Data Warehouse.

6. Any questions regarding the Consult Toolbox should be directed to Dr. Clinton Greenstone, Deputy Executive Director, Clinical Integration, Office of Community Care at Clinton.Greenstone@va.gov or Dr. Charles Demosthenes, VISN 7 Physician Lead for Analytics and Connected Care at Charles.Demosthenes@va.gov.

7. Questions regarding national consult policy and processes should be directed to Natasha de Silva, National Consult Program Manager, Office of Veterans Access to Care, at Natasha.Desilva@va.gov.

Note: See message from Office of Community Care Communications on February 22, 2018 to view PDF version of the 10N memo.

Update: Standardized Episodes of Care Initiative

As the VHA Office of Community Care (OCC) continues to develop new Standardized Episodes of Care (SEOCs) and incorporate feedback from facilities to edit existing SEOCs, OCC would like to inform you of some of the changes that have recently occurred or will be happening in the near future.

We appreciate the feedback and draft templates that many sites have provided thus far. If there are SEOCs your site would like to see created, please submit your request to the SEOC team using the following email address: Anthony.Dargiewicz@va.gov.

1. The table provided below displays the phases in which SEOCs have been deployed and provides the date each Veterans Choice Program (VCP) contractor is expected to have the SEOCs loaded into their respective referral systems.

• What this means to facilities is that SEOCs that are indicated as “Choice Mandatory” will automatically be assigned by the VCP contractors for any 10-0386 or PC3 authorization that requests a category of care that has a mandatory SEOC template as designated on the SEOC SharePoint.
• For instance: If a facility were to request a Rheumatology service using a 10-0386 form through a VCP contractor before January 2, 2018 the contractor will follow the instructions on the 10-0386 form. If the facility requests the same Rheumatology service using a 10-0386 form ON or AFTER January 2, 2018, then the VCP contractor will automatically apply the Rheumatology SEOC.

2. SEOCs can be used for all community care programs to include PC3, Provider Agreements and traditional community care (i.e. NVCC)/individual authorizations. Please note that SEOCs identified as “Choice Mandatory” will also be automatically applied to any PC3 referral that requests a category of care with a mandatory SEOC. Example: If your site submits a PC3 referral for Physical Therapy to a Choice contractor, the contractor will assign the SEOC to that episode of care even if it was not requested in the PC3 authorization/referral. This is being done to reduce Secondary Authorization Requests (SARs) and delays in care for Veterans.

3. Due to access limitations with community providers, the Colonoscopy Screening, Orthopedic and Ophthalmology SEOCs have been edited to increase their duration to 180 days to improve the ability to use these SEOCs with individual (community care) and provider agreement authorized services.

4. The Cardiac Rehab SEOC has been updated and has a new version number. The visits have been extended to 36 visits over 180 days (it was previously 24 visits in 90 days).

5. The next version of the Consult Toolbox (1.0.7) will allow staff to select any of the Phase 1 and 2 SEOCs using a drop down selection option in the Authorization tab of the Consult Toolbox. The remaining templates will be available via the SEOC SharePoint and will still require the information to be copy/pasted into the consult and 10-0386(a) or FBCS authorization. We will be changing the formatting of the SEOCs to a text (.txt) file over the next month so that the templates that remain on the SharePoint will have the same formatting as those in the Consult Toolbox.

6. Phase 3 SEOCs have been posted to the SEOC SharePoint. Those templates include the following services: Oncology Comprehensive, Nuclear Medicine, Vascular Surgery, Thoracic Surgery, Anti-Coag Lab, Pulmonary Bronchoscopy.

7. There will be more phases of SEOC releases as VHA transitions into the new Community Care Network contract. The Office of Clinical Integration will continue to develop new SEOCs and improve existing templates in collaboration with National Program Offices and VHA facilities.

We appreciate any and all feedback to help the SEOC initiative ensure we are meeting the needs of VHA facilities across the country and creating consistent standards of care for all Veterans to receive their care in a timely manner.

Support

• Questions? Contact Anthony.Dargiewicz@va.gov
• Access SEOC templates on the SEOC SharePoint.

Migration of eRevenue Resource Website

The OCC eBusiness Solutions team is pleased to announce the migration of the eRevenue Resource site is now complete (moved from SharePoint 2010 to SharePoint 2013). Please note the new URL in the link above.

We encourage you to save this in your favorites. We will continue to maintain the most current and up-to-date EDI resources. Some highlights include:

• Simple navigation to all pages from top and bottom navigation – no more pull-down menu to navigate through
• Search feature works!
• Email feature allows user to select station number and page-specific topic to populate the subject line to better manage specific threads

The site is fairly intuitive, and we do not anticipate problems with the transition. Your patience and support has been very much appreciated.

Support

• Questions may be sent to Marian Carter.

Release of VHA Directive 1601D.02 Treatment of Allied Beneficiaries

Purpose: VHA Directive 1601D.02 outlines the policies for providing VA health care benefits to allied beneficiaries.

Authority: Title 38 United States Code (U.S.C.) section 109.

Policy: It is VHA policy to provide medical, surgical, and dental treatment, hospital care, transportation and traveling expenses, prosthetic appliances, education, training, and/or similar benefits to allied beneficiaries; including Czechoslovakian or Polish beneficiaries. The Secretary may also pay the court costs and other expenses incident to the proceedings taken for the commitment of such discharged members who are mentally incompetent to institutions for the care or treatment of mental illness.

Support

• Please contact Kenneth L. Heyward at 202-382-2536 or Kenneth.Heyward@va.gov if you have a question about this policy.

CPT Codes 95004 and 95044

The OCC, Revenue Operations, Payer Relations, Rates and Charges team recently reviewed recently reviewed the data sources used to determine the charges for CPT codes 95004 and 95044. As a result the charges for these codes have been updated.  There are two processes that need to be followed for correcting the charges within the VistA billing system. We recommend using the Charge Master instructions under #1 below for adjusting 2017 claims and using the instructions under #2 below for 2018 claims.

In this announcement, we are providing detailed instructions on how to update the charges in the Charge Master Menu in VistA. Please note that these changes are applicable to all VAMCs and Provider-Based CBOCs. Once you have reviewed the detailed Charge Master instructions, refer to the 2017 Station Listing file below to obtain the appropriate station charges for these codes. Please note that these changes do not apply to Non-Provider Based Facilities. The Charge Master Instructions should only be used for the 2017 Outpatient Facility Charges.

2017 Dates of Service

In the Excel document referenced below, an example is highlighted in yellow for station 442, CHEYENNE VA MEDICAL CENTER, WY. When reviewing the Excel spreadsheet to obtain your Sites charges, first identify your station number in Column A then look at columns J and K for your charges for the respective CPT Codes. The CPAC staff will be responsible for entering the adjusted charges in the Charge Master.

1. Charge schedules have been developed by Facility Station Numbers with the new Geographic Area Adjustment Factor (GAAF) adjusted charges for both 95004 and 95044 for 2017.  We recommend that each Billing Manager or Supervisor edit the charges for these codes (for each division) in the Charge Master with the instructions provided below.  If it is revised in this fashion the change will remain in your system until the V3.23 2018 Outpatient patch update is released.  The Billing Manager can use the Enter/Edit Charge Master option in the Charge Master Menu to change the charge items if he/she has the ‘IB SUPERVISOR’ key or contact your IRM staff to input these changes for you.  This option is the recommended process that will provide less work for the billing staff for services rendered in CY 2017.

Note: To view the 2017 Facility Listings (Word file) and Charge Master Instructions (Excel file), see message released from Office of Community Care Communications on February 26, 2018.

2018 Dates of Service

2. However, for CY2018 we recommend that your billing staff make these changes during the billing process. All billers should utilize the new charge table and follow the guidance below to override the current facility charge amounts that have already been loaded. The patch for V3.23 will be released in March 2018 which will include the new charges for codes 95004 and 95044. Therefore it is better to adjust the 2018 claims on a case by case basis.  

Note: Please keep in mind for 2018 claims, when the Biller changes the charges on screen 7, this change will not remain in the system and will need to be made each time these codes are billed.

• The biller will have to go to screen 7, into #5 and replace the existing charge $XXX.XX with the new GAAF adjusted charge provided for your site. The biller will also have to make sure that the quantity/units being billed (that the coder entered in PCE) is correctly transferred under #5 in order for the correct charge to calculate and populate on the claim to get the billed charges for CY2018. Hit the “Enter Key” to exit out of the billing screen to make sure the new charge(s) came through. 

Note: To view the 2018 Facility Listings (Excel document), see message released from Office of Community Care Communications on February 26, 2018.

Support

If you have additional charge questions you may contact the Rates and Charges Team:

• Romona Greene at romona.green@va.gov.
• Charles M. Riley at charles.riley2@va.gov.
• Maureen Rocco at maureen.rocco@va.gov.

Collections and POWER Plus Reports for January 2018

The Monthly Medical Care Collections Fund (MCCF) Collections for January FY18 have been recorded at $308,524,234. Through the fourth month of FY18, 32.35% of the fiscal year goal has been allocated. The cumulative Fiscal Year-To-Date (FYTD) Total Collections, $1,147,493,501, amounted to 35.08% of the fiscal year goal. With four months of the fiscal year complete, our collections pace is 108.5% of the FYTD Expected Results.

Thank you for your diligent efforts in helping us exceed the goal of $3.27B that was outlined in the President's Budget.

The POWER Plus reports can be accessed here.

VA to Take Immediate Actions on Timely Payments to Community Providers

On January 3rd, the U.S. Department of Veterans Affairs announced a series of immediate actions to improve the timeliness of payments to community providers.

The actions will address the issue of delayed payments head-on and produce sustainable fixes that solve ongoing payment issues that affect Veterans, community providers and other VA partners.

“It is vital to the health of our network of providers that we provide payment in a timely and consistent fashion,” said VA Secretary Dr. David J. Shulkin. “Our outside providers are an essential part of our network and we need to improve our system of payments for their services.”

VA will immediately take the following short and long-term actions to improve payments to community providers. Short-term actions include:

• Publish a list identifying providers with high dollar value of unpaid claims, to be published the week of Jan. 8 at the following website: https://www.va.gov/COMMUNITYCARE/providers/info_payments.asp
• Create rapid response teams to work on the ground with these providers to reach financial settlement within 90 days.
• Increase the number of claims processed by vendors by 300 percent in January 2018 and by 600 percent in April 2018 with a goal of 90 percent clean claims processed in less than 30 days.
• Establish multiple entry points for providers to check the status of their claim, including a dedicated customer service team and VA’s Vendor Inquiry System (VIS) located at https://www.vis.fsc.va.gov.

In addition, long-term actions include:

• Deploy multiple IT improvements within the first six months of 2018 that streamline the claims submission and payment process to reduce time for payments significantly.
• Align on concurrent performance improvement goals with VA’s existing Third Party Administrators to improve multiple aspects of their performance rapidly to ensure Veterans have continued uninterrupted access to care.
• Award four new contracts in 2018 for implementation in 2019 to establish the new Community Care Network that includes elements designed to ensure prompt payment of claims.
• Work with Congress to consolidate and simplify all VA community care programs, including provisions for prompt payment of claims.
• Ensure transparency with VA’s claims processing performance by publishing VA’s claims processing timeliness on a monthly basis.

Amended VA Emergency Care Regulation

The VHA Office of Community Care announced that VA will start processing claims for reimbursement under Title 38 U.S.C. 1725 of the reasonable costs of non-VA emergency treatment for eligible Veterans’ non-service connected conditions where only partial payment is made by the Veteran’s other health insurance (OHI). Reimbursable costs include hospital charges, professional fees, and emergency transportation, such as ambulances.

In accordance with the amended Federal regulation (Title 38 C.F.R. 17.1005) for non-service connected emergency treatment published in a Federal Register notice on January, 9, 2018, for claims pending with VA on or after April 8, 2016, Veterans or their providers may now be eligible to receive payment if the OHI did not cover certain costs associated with the emergency treatment. VA is prohibited from reimbursing Veteran OHI member liabilities such as copayments, cost shares and deductibles.

The Claims Adjudication and Reimbursement (CAR) Office will contact community providers to obtain any additional information needed to review and process the claim.

These changes support VA’s mission to care for those who have borne the battle and its commitment to provide quality and timely healthcare for its Veterans when and where they need it.

More information on the amended regulation and guidance on reimbursement can be found here.

Dr. Kameron Matthews, Acting ADUSH for Community Care

The VHA Office of Community Care is pleased to announce Kameron Matthews, MD, JD, will be detailed to the role of Acting Assistant Deputy Under Secretary for Health for Community Care beginning January 8, 2018.

Dr. Matthews is the Deputy Executive Director, Provider Relations and Services, within the Office of Community Care where she is responsible for the community-based provider network that increases access to care for veterans nationwide. She previously served as the Chief Medical Officer of Mile Square Health Center within the University of Illinois Hospital and Health Sciences System, overseeing thirteen interdisciplinary primary care sites within the federally qualified health center (FQHC). She also served as a Medical Director with the System's Department of Managed Care and assisted with the creation of the Medicaid accountable care entity UI Health Plus. Her work with FQHCs as well as within the correctional system has focused on issues pertaining to access to care, health disparities, and population health management.

Dr. Matthews is a board-certified family physician with a focus on underserved medicine and advocacy. She serves on committees of the National Association of Community Health Centers (NACHC). She is honored to been awarded the 2017 National Minority Quality Forum’s 40 Under 40 Leaders in Minority Health, 2015 National Medical Association Council for the Concerns of Women Physicians Emerging Trailblazer Award, the 2015 NACHC Health Professions Education and Training Award, and the 2015 Congressional Black Caucus Foundation Health Braintrust Congressman Louis Stokes Public Health Advocate Award.

Along with being committed to improving care for Veterans, Dr. Matthews brings a wealth of ideas, knowledge and leadership experience that will be crucial to our organization during this season of change with VA’s community care programs.

New Video: VA Community Care - Community Viewer

The VHA Office of Community Care (OCC) is pleased to announce the release of a new video entitled, “VA Community Care - Community Viewer”. The video discusses a new technology being deployed nationally that advances the secure sharing of Veteran electronic health records (EHRs) between VA and community providers. Learn more about Community Viewer.

This technology is a great example of the efforts being made nationally by VA to make processes more efficient and improve care coordination for Veterans when they receive care from community providers. Please distribute and/or post the video as widely as possible to all interested parties, including community care providers. Sample social media posts and a downloadable video file are located here.

Thank you for your support in making these process enhancements possible and for helping communicate the advances we’re making to improve care for Veterans.

VA Medical Facilities Can Now Use CoverMyMeds

The Office of Community Care (OCC) is pleased to announce that VA medical facilities can begin using CoverMyMeds (CMM). CoverMyMeds is a free tool for electronically obtaining prior authorization for medications from third party insurance carriers, used primarily by pharmacists and utilization review nurses. Obtaining prior authorization of medication maximizes the reimbursement rates paid to VA, increasing collections and revenue associated with VA dispensed prescription medications.

In FY2017, OCC provided information to VISNs on the benefits of using CMM. However, CMM could not be utilized until the required Business Associate Agreement (BAA) was completed and the Terms of Service with CMM was approved for usage by VA. The BAA between CMM and VA has been completed and released, and can be found here: http://vaww.vhadataportal.med.va.gov/PolicyAdmin/BusinessAssociateAgreements.aspx.

In addition, the Information Security Office (ISO), Privacy Office and Office of General Counsel (OGC) have determined that the existing Terms of Service Agreement can now be utilized by VA users.

Please share this information with your Pharmacy Executives and staff. If you have questions about using CoverMyMeds, please contact the Revenue Transformation Billing & Collections team lead Larisa Nightingale, Director Central Plains CPAC at Larisa.nightingale@va.gov.

Automation of the Technical Component (TC) Modifier in VistA

Revenue Operations Payer Relations Services (PRS) Rates and Charges is pleased to announce the release of patch IB*2.0*564 within VistA that will automate the Technical Component (TC) modifier on the UB-04 claim in the Integrated Billing (IB) Package. The release date is 01/16/2018 with a compliance date of 02/10/2018. The effective date of this patch will be the date the patch is installed. This announcement supersedes any previous guidance provided regarding the use of the TC modifier when billing.

Background

Historically, the TC modifier was not being appended and third party payers were denying the professional charge, stating that the VA billed the global charge on the institutional bill with no TC modifier. VA does not bill a global charge for provider-based facilities. The purpose of automating the TC modifier is so that VA will be reimbursed for both the institutional and professional charges.

The TC modifier applies to (70000 series of CPT codes) radiology, radiation, and nuclear medicine (not all 70000 series codes use the TC modifier). In addition, there are other CPT codes (see January 19, 2018 message from Office of Community Care Communications, which includes an attachment) that also require the use of the TC modifier and must be appended to the institutional UB-04 bill. TC modifiers are appended to CPT/HCPCS codes through the Lexicon Patch process.

The TC modifier is appended to all appropriate codes on the institutional UB-04 claim in order to prevent denials of the professional component (26 modifier) by Third Party Payers. Important: Medicare/Novitas does not accept the TC modifier and will deny the claim if the modifier is appended. However, when billing the Other Health Insurance, secondary to Medicare, you will have to append the TC modifier.

In order to remove the TC modifier for Medicare/Novitas Billing, see below process:

Example: Go to [4] Code Method on screen <5> of the Enter/Edit Billing Information [IB EDIT BILLING INFO] option:

Select CPT MODIFIER SEQUENCE: 1// @
SURE YOU WANT TO DELETE THE ENTIRE '1' CPT MODIFIER SEQUENCE? Y (Yes)

Apply Procedure Updates for Charges? YES// NO

Please share this information with Regional Revenue Managers, Billing Managers, Billing Supervisors, and all Billing Staff, in addition to anyone else that would need to be aware of this enhancement.

Support

Please input any question you may have about this announcement into the Office of Community Care Q&A website located at the following link: https://vaww.va.gov/CBO/apps/qanda/index.cfm. Input a key word related to your search (e.g. – “reasonable charges”). If you are not able to see the answer you need based on your key word search then you may submit a new question by selecting the “Submit a Question” link at the top of the Q&A web page.

CY2018 National Average Administrative Prescription Drug Charge For Outpatient Prescriptions 

Revenue Operations Payer Relations and Services (PRS) Rates and Charges is pleased to announce the release of patch IB*2.0*610 for the CY2018 annual update for the National Average Administrative Prescription Drug Charge used for billing 3rd Party Pharmacy Prescription Drugs furnished by the VA to a Veteran for a Non-service-Connected disability.

More specifically, VA has amended the National Average Administrative Prescription Drug Charge used for billing the Outpatient prescription drugs not administered during treatment. The Reasonable Charges Notice for CY2018 charge updates that includes the National Average Administrative Prescription Drug Charge was published on Thursday, 12/14/2017 in the Federal Register, Vol. 82, No. 239, pages 59213-59214. This notice allows for the update of Outpatient, Professional and Pharmacy Prescription administrative drug charges for CY2018 which have an effective date of 1/1/2018. The IB*2*610 patch was released to the field on Friday, 1/19/2018 with a compliance date of 2/19/2018. This patch updates the national average administrative charge for Outpatient prescriptions to $16.64 based on VA’s national administrative costs associated with dispensing the drugs for each prescription.

This patch will inactivate rate schedules containing the RX Charge set for rate types: Reimbursable Insurance, No Fault Insurance, Tort Feasor, Ineligible, Humanitarian, Workers Compensation, and Cost-Based and Interagency rates with an inactive date of 12/31/2017 and add the new administrative fee of $16.64 for those same rate types to the new rate schedules with an effective date of 1/1/2018. Once IB*2*610 is installed, the patch will be retroactive to 1/1/2018.

See the Federal Register PDF file and the link below:

https://www.gpo.gov/fdsys/pkg/FR-2017-12-14/pdf/2017-26950.pdf

See January 23, 2018 message from Office of Community Care Communications for the patch description and install process.

The Reasonable Charges V3.23 Federal Register Notice which includes the National Administrative Prescription Drug Charge, updated for CY 2018 was made available on 1/1/2018 on both the VHA Office of Community Care internet and intranet sites with an effective date of 1/1/2018. To access this information please use the links below:

Internet: https://www.va.gov/COMMUNITYCARE/revenue_ops/payer_rates.asp

Click on “Reasonable Charges V3.23”

Intranet: http://vaww.va.gov/CBO/rcbilling/reaschgs.asp

Click on “Reasonable Charges V3.23”

Please input any question you may have about this announcement into the Reasonable Charges Website for Q&A's located on the Office of Community Care website at: http://vaww1.va.gov/CBO/apps/qanda/index.cfm. Input a keyword related to your search (e.g. – “reasonable charges”). If you are not able to see the answer you need based on your keyword search then you may submit a new question by selecting the ‘Submit a Question’ link at the top of the Q&A web page.

Enterprise Denials Dashboard Release #2

As a part of our commitment to improve processes related to denials management, an enterprise-level dashboard has been developed to track denials with updated metrics and reporting capabilities. The dashboard incorporates functionality to run reports to identify problematic areas and root causes of denials. The goal is for VAMC and CPAC leadership to partner together to use the dashboard to identify denials as well as develop corrective action plans to prevent them in the future. As someone who has been identified as a potential dashboard user, you are receiving this email to provide you with information on Release #2 of the Enterprise Denials Dashboard and upcoming training sessions that have been planned.

Access to Enterprise Denials Dashboard Release #2 will be available on January 25, 2018. This release specifically provides:
1. Metrics for post-denial payments, outstanding denial volumes, and outstanding denied dollars
2. Filters by True Denial, Payer, and CPT/Procedure Code
3. Daily Incremental Data Integration
4. Denials Volume and Dollar Trend Charts (month to month and year to year)

To access this software, visit VAPulse.net and sign up for an account. VA Pulse is a VA-approved and secure social network that is used for business and networking. From there, visit the FSC Data Analytics Request form, read and agree to the Terms of Use, and then choose Enterprise Denials from the drop-down menu provided. Fill out the rest of the spaces in the form and click “Submit” from there. A step by step guide to filling out the online form is attached to this message.

Once completed, a technology access request form will be given to approvers and you will be sent a membership invite for the Enterprise Denials Dashboard VA Pulse group page, all within one-to-two business days. Here you can view training manuals and videos for the product.

Should you have questions please contact Tobey Cummings, Director, West Consolidated Patient Account Center (WPAC) at (702) 341-3010 or by email at Tobey.Cummings@va.gov.

Collections and POWER Plus Reports for December 2017

The Monthly Medical Care Collections Fund (MCCF) Collections for December FY18 have been recorded at $265,513,991. Through the third month of FY18, 24.0% of the fiscal year goal has been allocated. The cumulative Fiscal Year-To-Date (FYTD) Total Collections, $838,969,267, amounted to 25.7% of the fiscal year goal. With three months of the fiscal year complete, our collections pace is 106.9% of the FYTD Expected Results.

Thank you for your diligent efforts in helping us exceed the goal of $3.27B that was outlined in the President's Budget.

The POWER Plus reports can be accessed here.

Ensuring Proper Management of VHA Organization NPI Numbers

This message is a reminder to all VA medical facilities that VHA organization National Provider Identifiers (NPIs) must only be applied for and managed by the VHA Office of Community Care (OCC) eBusiness Solutions NPI Team.

Since NPI was established in 2008, the eBusiness Solutions NPI Team assumed sole responsibility in VHA for the application and management of all VHA organization NPI numbers. Organization NPI numbers relate to all VHA billable sites of care including VAMCs, CBOCs, clinics, pharmacies, etc. This stands in contrast to VHA provider NPIs, which are maintained by VHA medical facilities, as stated in VHA Directive 1066. VHA provider NPIs relate to billable providers themselves.

In mid-2017, the Centers for Medicare and Medicaid Services (CMS) updated their Identity and Access (I&A) Management System, making it possible for any VHA staff member to access and be able to provide a specific form from the Internal Revenue Service to apply for or make changes within the National Plan and Provider Enumeration System (NPPES) for VHA organizations. Since this change, the eBusiness Solutions NPI Team has seen an increase of instances where VHA staff have either applied for a VHA organization NPI or made changes to an established VHA organization NPI. This causes delays in VHA revenue activities and third party health insurance claims processing, and leads to VHA and third party payer systems to be out of sync, increasing the potential for delays and decreases in revenue.

Please distribute this message widely, reminding all staff that VHA organization National Provider Identifiers (NPIs) must only be applied for and managed by the VHA Office of Community Care (OCC) eBusiness Solutions NPI Team.

Questions? Please contact Erin Potter (erin.potter@va.gov)

Community Care Utilization Management Program Guidance

1. The purpose of this memorandum is to provide direction on the projects that support the Veterans Health Administration (VHA) Office of Community Care (OCC) Utilization Management (UM) initiative.

2. UM projects provide Veterans Affairs Medical Centers (VAMC), VISNs, and VHA OCC with increased standardization and oversight of community care services. These projects will also refine clinical review processes, enhance guidance on authorizing services in the community, and optimize management of Secondary Authorization Requests (SARs) (see Appendix A-C). Through this memorandum, VHA OCC requests that all VAMC Directors and Chiefs of Staff complete the following:

a. Assign delegation authority for reviewing all services listed in the updated DOAMS List template to appropriate clinical reviewers, and re-submit the signed DOA Memo and DOAMS List on the DOA Solutions Page SharePoint. The DOAMS List now includes services listed in the Prior Authorization List (PAL). Additional information on PAL processes can be found on the PAL Solutions Page.

b. Add any additional delegation authorities for services that are not currently included on the DOAMS List but are approved frequently at your VAMC to the DOAMS List Template. Additional instructions can be found at the DOA Solutions Page.

c. Ensure that there is a standardized clinical review process for all PAL services that are included in consults and/or secondary authorization requests (SARs). Clinical reviews should be conducted by reviewers identified in the facility level DOAMS List. Information is available on the PAL Solutions Page and in the Field Guidebook.

d. Ensure the use of available Standardized Episodes of Care (SEOCs) to authorize community care services when clinically appropriate. As of the date of this memo, 55 SEOCs are available on SharePoint.

3. These actions must be documented as completed on the Community Care Dashboard in SharePoint before February 14, 2018.

4. The Oversight Council at each VAMC is responsible for providing oversight and regulation of DOA, PAL and SEOC Processes.

5. Any questions should be directed to Dr. Clinton Greenstone, Deputy Executive Director, Clinical Integration, VHA Office of Community Care (Clinton.Greenstone@va.gov); Tony Dargiewicz, Chief, Patient Administration Services (Anthony.Dargiewicz@va.gov); or Jennifer Peppiatt, Clinical Program Analyst, VHA Office of Community Care (Jennifer.Peppiatt@va.gov)

TPA Timeliness VSSC Report

VA is continuing to focus on people, process, and technology to improve our processes to refer Veterans to Community Care. As a follow-up to the data distributed as part of the Interim Solution to Track Timeliness, the Community Care Support Center (CCSC) and VHA Support Service Center (VSSC) have developed an automated report for VAMCs to monitor end-to-end referral processes for Veterans Choice Program referrals scheduled by HealthNet or TriWest. VAMCs can use this data to understand, manage and improve upon the referral creation and appointing processes.

The data provided within the report shows the timelines for steps performed by both VHA and the contractor for both Choice First and Wait Time Eligibility. Currently, the report contains data through November 22, 2017. This data will be updated weekly for the previous week on an ongoing basis. Please see the attached fact sheet, ‘VCP Referral Cycle Time Report’, for further instruction on accessing this report.

The CCSC will monitor the VSSC report on an ongoing basis to identify trends and support performance improvement opportunities. We also encourage each VISN and VAMC to monitor its own data as follows:

• Review the results, including facilities with low sample sizes (number of authorizations or matches), and identify any potential data nuances that may affect their indicated performances 
• Investigate, document, and report any anomalies (e.g. surprisingly high or low average times) 
• Understand performance variances between facilities within the VISN and identify opportunities to standardize performances 
• Collaborate with other VISNs to determine leading practices that can be incorporated to enhance referral timelines

TPA Timeliness VSSC Report

Please contact Amanda Barnes (amanda.barnes@va.gov) or Muriel Varner (muriel.varner@va.gov) with any data-related questions.  Thank you for your continued hard work and dedication to improving the experience of Veterans and their families, community providers, and VA staff.

Reasonable Charges Inpatient Rate Update for FY 2018

The Office of Community Care Revenue Operations CPAC Rates and Charges Office is pleased to announce that Reasonable Charges Version 3.22 Patch IB*2.0*600 for FY 2018 Annual update for Acute Inpatient MS-DRG facility charges and Skilled Nursing facility charges/Sub-Acute Inpatient facility charges was released to the field Thursday, January, 4, 2018 with a compliance date of January 19, 2018.

Reasonable Charges Version 3.22 update was published on Monday, September 25, 2017 in the Federal Register Vol. 82, No. 184 page 44701. This revision provides updated charges for FY2018 MS-DRG’s and will impact Inpatient/Sub-acute and Skilled Nursing Facility charges.

Below is the document and link for the federal register notice:

https://www.gpo.gov/fdsys/pkg/FR-2017-09-25/pdf/2017-20423.pdf

The charge structure in Version 3.22 has a slight change with the deletion of three MS-DRGs. Please see the table below. Also, the Per Diem facility charges for all MS-DRGs have changed. Once installed, the patch will be effective retroactive to October 1st, 2017.

For the October update, CMS has:

• Reduced the number of MS-DRGs from 757 to 754 for FY 2018. 
• CMS is not implementing any new MS-DRGs for FY 2018. 
• In addition, CMS is deleting MS-DRGs 984, 985 and 986.

The Federal Register notice, charge tables and all associate tables for the FY18 update of Reasonable Charges for Inpatient MS-DRGs and SNF Medical Services; V3.22, Fiscal Year 2018 are posted on the VHA Office of Community Care Intranet and Internet sites below:

VHA Intranet Site:

http://vaww.va.gov/CBO/rcbilling/reaschgs.asp Click on “Reasonable Charges Data Tables V3.22”

VHA Internet Site:

https://www.va.gov/COMMUNITYCARE/revenue_ops/payer_rates.asp Click on “Reasonable Charges Data Tables V3.22”

Please input any question you may have about this announcement into the Reasonable Charges Website for Q&A's located on the VHA website at: http://vaww1.va.gov/CBO/apps/qanda/index.cfm. Input a keyword related to your search (e.g. – “reasonable charges”). If you are not able to see the answer you need based on your keyword search then you may submit a new question by selecting the ‘Submit a Question’ link at the top of the Q&A web page.

Veterans Choice (VC) Viewer Decomissioning

Extension

Effective November 15, 2017, access to the Veteran Choice (VC) Viewer application by VA staff was discontinued. Instead, users may access VC Viewer information by accessing the Enrollment System, which is the definitive system for identifying eligibility and enrollment determinations for all VA health care. The Enrollment System must be used by all VA facility staff involved in confirming eligibility for community care options.

Accessing Enrollment System

All users who need to view VCP eligibility must have access to the Enrollment System. To access:

• If you are an Enrollment System and VC Viewer user, no changes are required to your Enrollment System account access. You may log on with your PIV at https://vaww.esr.aac.va.gov/esr/.
• If you do not have access to the Enrollment System, contact Member Services at CommunityCareAccessGroup@va.gov to obtain view-only access.

Support

• Training for Community Care Eligibility within Enrollment System
• Contact CommunityCareAccessGroup@va.gov with questions.
• VCP Resource Toolkit

Cost-Based and Inter-Agency Rate Update 2017-2018

The Office of Community Care, CPAC Revenue Operations, Rates and Charges Office is pleased to announce the release of patch IB*2.0*603 for the update of the Cost-Based and Interagency Rates. The patch was released on Tuesday, December 26, 2017 with a compliance date of Friday, January 26, 2018.

The patch allows for the update of charges for Cost-Based and Inter-Agency Rates with an effective date of August 29, 2017. The charge structure for this version of the Cost-Based and Inter-Agency Rates will remain the same as in previous versions, but the charge amounts changed. Once IB*2.0*603 is installed, the patch will be retroactive to August 29, 2017.

The notice for this rate update can be found in the Federal Register, Vol. 82, No. 166, page 41093. Below is the attachment and link for the federal register notice for the Cost-Based and Inter-Agency Rate (CBIAR) table:

https://www.gpo.gov/fdsys/pkg/FR-2017-08-29/pdf/2017-18219.pdf

The Cost-Based and Inter-Agency Rates have been posted on the VHA Intranet and Internet sites below:

VHA Intranet Site:
http://vaww.va.gov/CBO/rcbilling/reaschgs.asp
Click on ‘Cost-Based and Interagency Rates Information, 8/29/17’

VHA Internet Site:
https://www.va.gov/communitycare/revenue_ops/payer_rates.asp
Click on ‘Cost-Based and Interagency Rates Information, 8/29/17’

Please input any question you may have about this announcement into the Reasonable Charges Website for Q&A's located on the VHA website at: http://vaww1.va.gov/CBO/apps/qanda/index.cfm. Input a keyword related to your search (e.g. – “reasonable charges”). If you are not able to see the answer you need based on your keyword search then you may submit a new question by selecting the ‘Submit a Question’ link at the top of the Q&A web page.

Recognizing Two OCC Leaders Recently Published in Medical Care Journal

I would like to recognize two of our VHA Office of Community Care (OCC) leaders, Dr. Kameron Matthews, Acting ADUSH for Community Care, and Dr. Clinton (Leo) Greenstone, Deputy Executive Director, Clinical Integration, whose work, along with several co-authors, was recently published in the journal Medical Care, a publication of the American Public Health Association.

The article published in Medical Care is a letter-to-the-editor that was a follow-up to an article published in the July 2017 Medical Care Supplement entitled “Where’s My Choice?” An Examination of Veteran and Provider Experiences With Hepatitis C Treatment Through the Veteran Affairs Choice Program”. The original article described the challenges VHA experienced with rapid policy deployment during implementation of the Veterans Choice Program, and considered whether VHA acted as a learning organization as it responded to the program’s shortcomings. To do this, the authors looked specifically at how care was provided to Veterans with hepatitis C virus (HCV) through the Choice program.

Dr. Matthews and Dr. Greenstone contributed to a follow up letter-to-the-editor to the original article that describes actions taken and substantial progress made by VA in reforming community care, specifically with respect to Veterans with HCV. Please take a moment to review the letter (click here to view on VA Pulse) and the table showing the many specific, detailed improvements VA has made to how community care operates.

Please join me in congratulating Dr. Matthews and Dr. Greenstone, and I also want to thank the entire OCC team for all your hard work in making these improvements to community care possible. Great work!

-Amy Fahrenkopf, MD, MPH
Acting Deputy Under Secretary for Health for Community Care