[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
ASSESSING VA'S ABILITY TO PROMPTLY PAY
NON-VA PROVIDERS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, JUNE 3, 2015
__________
Serial No. 114-24
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
____________
U.S. GOVERNMENT PUBLISHING OFFICE
98-641 WASHINGTON : 2016
________________________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].
COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
GUS M. BILIRAKIS, Florida JULIA BROWNLEY, California,
DAVID P. ROE, Tennessee Ranking Member
TIM HUELSKAMP, Kansas MARK TAKANO, California
MIKE COFFMAN, Colorado RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana BETO O'ROURKE, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Wednesday, June 3, 2015
Page
Assessing VA's Ability to Promptly Pay Non-VA Providers.......... 1
OPENING STATEMENTS
Dan Benishek, Chairman........................................... 1
Julia Brownley, Ranking Member................................... 2
WITNESSES
Asbel Montes, Vice President of Reimbursement and Government
Affairs, Acadian Ambulance Service............................. 4
Prepared Statement........................................... 33
Vince Leist, President and Chief Executive Office North Arkansas
Regional Medical Center, On behalf of the American Hospital
Association.................................................... 5
Prepared Statement........................................... 34
Sam Cook, President, National Mobility Equipment Dealers
Association.................................................... 7
Prepared Statement........................................... 37
Gene Migliaccio Dr. P.H., Deputy Chief Business Officer for
Purchased Care, VHA, U.S. Department of Veterans Affairs....... 9
Prepared Statement........................................... 49
Accompanied by:
Joseph Enderle, Director, Purchased Care Operations, VHA,
U.S. Department of Veterans Affairs
STATEMENT FOR THE RECORD
Hon. Charles W. Boustany Jr., M.D................................ 52
Prepared Statement by Debora M. Gault on American Medical
Response....................................................... 61
AMR PBS Report................................................... 68
Statement by Greg Hufstetler on Reimbursement Technologies,
Inc.--A Subsidiary of EmCare, Inc.............................. 73
ASSESSING VA'S ABILITY TO PROMPTLY PAY NON-VA PROVIDERS
----------
Wednesday, June 3, 2015
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC
The subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. [chairman of the
subcommittee] presiding.
Present: Representatives Benishek, Huelskamp, Coffman,
Wenstrup, Abraham, Brownley, Takano, Ruiz, and Kuster.
Also Present: Representative Walorski.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Dr. Benishek. Good morning. The subcommittee will come to
order.
Thank you all for joining us for today's subcommittee
hearing, ``Assessing VA's Ability to Promptly Pay Non-VA
Providers.''
The issue we will discuss this morning, VA's ability to
efficiently and accurately reimburse non-VA providers for the
services they provide to veteran patients on the Department's
behalf, has perhaps the most far-reaching implication of any
issue that we will discuss this Congress. It impacts small and
large hospital systems, individual providers and practice
groups, ambulance companies and emergency departments, home
health aides, mobility equipment dealers, and all manner of
others in communities across the country who find themselves
left holding VA's check, sometimes to the tune of millions of
dollars.
It impacts veterans, who are sometimes billed for services
that VA should have paid, which can damage both their credit
and their confidence in VA. And it also impacts the overall
success of VA healthcare system--a healthcare system that is
increasingly reliant on non-VA providers who are becoming more
and more hesitant to accept veteran patients for fear that VA
will not reimburse them for the services that they provide.
This morning, we will hear troubling testimony from some
non-VA providers who will outline persistent difficulties that
they have faced when attempting to obtain timely and accurate
payment from VA, overly burdensome VA guidelines that hinder
their ability to resolve issues with VA officials, and
inexplicable gaps between stated VA policy and day-to-day
practice in the field.
They will allege that they are owed, in some cases, tens of
millions of dollars over many years and have to fight VA for
every penny. They will allege that they have had to wait for up
to 4 hours on the phone when attempting to contact VA to check
on the status of a claim and then, after connecting with a VA
employee, were disconnected because they did not know the
veteran's middle name or tried to ask VA about more than four
claims on one phone call.
Perhaps most disturbingly, they will allege that VA has
lost sensitive medical documentation that they have provided to
support their claims even though they are able to demonstrate
via certified mail that VA received the documents in question.
What worries me almost more than the testimony that we will
hear today is the testimony that we won't hear today from those
who are reluctant to share their stories publicly out of fear
of retaliation. For example, a small business in my district
who has been unable to obtain timely payment from VA for
services provided to Michigan veterans elected not to provide
comments for today's hearing out of fear that coming forward
would negatively impact their relationship with VA leaders and,
therefore, their ability to get paid for the services that they
have rendered so far and to continue helping veterans in the
future.
Of course, all of this begs questions. If non-VA providers
are owed collectively hundreds of millions in backlog payments,
where is that money? Why is there such a wide variation in
claims processing from VA facility to VA facility? And why are
there such burdensome restrictions placed on non-VA providers,
who are simply looking to be reimbursed in a timely manner for
the valuable lifesaving services that they provide?
What retaliatory actions has VA taken against non-VA
providers that have caused many to be unwilling to publicly
relay their stories? How can VA expect to become a healthcare
leader when basic business functions cannot be completed
efficiently? And, most troublingly, what happened to medical
record information that VA is signing for and then claiming
never to have received? And how can we be sure that sensitive,
personal information has not been compromised by shoddy VA
recordkeeping?
These are just some of the many serious issues that we need
answers to this morning.
So, without further ado, I now yield to Ranking Member
Brownley for any opening statements she may have.
OPENING STATEMENT OF RANKING MEMBER JULIA BROWNLEY
Ms. Brownley. Thank you, Mr. Chairman. And thank you for
calling this hearing today.
Section 105 of the Veterans Access, Choice, and
Accountability Act required the Veterans Affairs to set up a
claims processing system. In addition, the Government
Accountability Office is to report it to us no later than 1
year after the law was enacted about the timeliness of payments
for hospital care, medical services, and other health care
furnished by non-Department of Veterans Affairs healthcare
providers. I understand the report is due August 7 of this
year, and I look forward to receiving the report from GAO.
The VA has struggled in the past to ensure that non-VA
providers are paid in a timely manner. Numerous past reports by
the GAO have found weaknesses in the management and oversight
of non-VA medical care.
In today's testimony submitted by Mr. Greg Hufstetler of
EmCare, he claims that EmCare has been unable to obtain
virtually any payments from the Veterans Health Administration
since the fourth quarter of 2013.
I understand that EmCare has treated over 59,000 veterans
without receiving payment. This concerns me greatly. I look
forward to hearing from VA how this could happen and what are
they doing to address the situation. Is this typical throughout
the healthcare system, or are there extenuating circumstances
involved in this particular instance?
According to VA testimony, since May of 2014, VA has
received 34 percent more claims than January 2015 through April
of 2015 as compared to the same time in 2014. That represents a
significant increase of claims into a system that was already
overburdened. I would like VA to tell the subcommittee what the
significant challenges are that affect the ability of VA to pay
on time.
Mr. Chairman, again, I want to thank the witnesses for
being here today to help inform the subcommittee how we can
improve the claims processing system of the Veterans Health
Administration. I look forward to their testimony, and I thank
you for holding the hearing.
And I yield back.
Dr. Benishek. Thank you, Ms. Brownley.
Joining us on our first and only panel this morning is
Asbel Montes, vice president of reimbursement and government
affairs for Acadian Ambulance Service; Vince Leist, president
and chief executive officer of the North Arkansas Regional
Medical Center, who is testifying on behalf of the American
Hospital Association; Dr. Gene Migliaccio, VA's Deputy Chief
Business Officer for Purchased Care, and he is accompanied by
Joseph Enderle, VA's Director of Purchased Care Operations. We
are also joined by Sam Cook, president of the National Mobility
Equipment Dealers Association.
I am going to yield to his Congresswoman, my friend,
colleague, and fellow committee member, Jackie Walorksi, to
introduce him.
Mrs. Walorski. Thank you, Mr. Chairman, for the opportunity
of allowing me to introduce my constituent Sam Cook, president
of Superior Van & Mobility in South Bend, Indiana, located in
my district.
Sam's father, Dan Cook, Sr., founded Superior in 1976. It
is a family-run business and today is currently one of the
largest mobility dealers in the country. Along with running a
growing company, Sam has acted with the National Mobility
Equipment Dealers Association, where in 2012 he assumed the
role of president of the board of directors.
I would like to welcome Sam and thank the chairman for the
indulgence.
Dr. Benishek. Thank you, Mrs. Walorksi.
Well, let's begin.
Mr. Montes, we will begin with you. Please proceed with
your testimony. You have 5 minutes. Thanks.
STATEMENT OF ASBEL MONTES
Mr. Montes. Chairman Benishek and Ranking Member Brownley
and distinguished members of the subcommittee, my name is Asbel
Montes, and I am the vice president of reimbursement and
government affairs for Acadian Ambulance Service. We are
located in Lafayette, Louisiana. We are the largest privately
owned, employee-owned ambulance service in the Nation.
The chairman and CEO of our company, Richard Zuschlag,
founded our company in 1971 with eight Vietnam veterans. Today,
we have over 4,000 employee-owners, with over 400 of those
being military veterans. So I am honored to sit before you
today to represent not only our industry but, even more so, the
veterans that we serve.
Prior to coming before you today, our company, along with
American Medical Response, who is the largest public ambulance
provider in the Nation, and the American Ambulance Association
have worked diligently with our congressional delegation, our
other healthcare stakeholders, the Veterans Integrated Service
Network, as well as the national leadership at VA to assist,
recommend, and, frankly, demand that VA's internal processes be
updated and modified to ensure that they are fulfilling their
intended purpose but also not placing a financial burden on the
men and women who have served our Nation so selflessly. Despite
these efforts, we have not seen any significant positive
movement from VA and, therefore, find ourselves here today.
For a real-life look at the issue, please allow me to
provide one example that a veteran in Louisiana experienced who
called 9/11 for emergency medical care and transport in early
2014.
We filed a claim and provided all the necessary information
and medical records and appropriate documentation within 30
days to VA. We sent this information via certified mail. VA
signed for it, confirming receipt, 5 days later. Almost a year
later, on March of 2015, the veteran appeared on two local TV
channels describing how his claim was still unpaid. He was
subsequently contacted by a VA representative on March the 18th
of 2015 indicating that his claim would be paid and he would
receive notification. The claim finally processed on April of
2015, over a year and 3 months later.
There are many more examples just like this that we could
provide you of other providers and veterans alike across the
Nation, but suffice it to say the GAO report in 2014, which
highlighted these issues regarding excessive claims processing
time and paperwork requirements for non-VA providers, is
absolutely correct.
This problem is especially acute for the majority of
ambulance services, providers that serve the local 9/11
responders and their communities, who are prohibited from
refusing emergency treatment from any patient regardless of
their payer source and the ability to pay.
The failure to pay providers in a timely and accurate
manner puts providers like us in the difficult position of
having to bill veterans for emergency treatment, placing an
unfair financial burden on the veterans due to the lack of
response, invalid denial or payment by VA.
Our previous efforts at addressing this issue have included
numerous increase sent from our Congressmen and Senators in
many States, and the responses from VA have remained wholly
inaccurate and inadequate.
My colleagues and I are not ignorant to the magnitude that
this issue presents for VA. However, after numerous offers of
assistance and requests for relief from the private and public
sector, we have seen very little change. In fact, our company,
American Medical Response, and many members of the American
Ambulance Association have seen a recent escalation of the
problem, with our accounts receivable due from VA growing in
excess of $30 million over 90 days.
VISN 16 has sent reports to our congressional delegates
with a number that would indicate improvement, but our data
clearly indicates the opposite. On May 14 of this year, just a
few weeks ago, we had yet another conference call with VISN 16,
specifically the Flowood, Mississippi, office, and requested
that they provide us with all claims that we filed to them
since 2012 in order to reconcile our records with theirs.
That audit, which we completed last Tuesday, indicated that
they showed no record of 768 claims which were sent certified
mail with confirmation of receipt. Last Thursday, just a few
days ago, they said they would investigate the discrepancy and
get back with us on Friday. As of this morning, when I spoke
with my staff at 9 o'clock, we still had not heard from their
office regarding that.
The Federal Government has a responsibility to ensure that
our veterans receive the best health care we can provide. It
also has the responsibility to ensure that they are not
required to bear an unjustified financial burden because VA
fails to pay non-VA providers in a timely and accurate manner.
It is our recommendation that Congress remove all claims
processing for non-VA providers from the Department of Veterans
Affairs and place it with a single fiscal intermediary,
providing guidelines and policies to address the issues stated
here today. These steps would ensure consistency, efficiency,
and expertise in personnel, as well as sufficient, dedicated
resources to process claims timely. Several other government
programs, such as TRICARE and Medicare, utilize this strategy
successfully, but note that time is of the essence.
Thank you for giving me this opportunity to provide this
information and serve those who have sacrificed so much for our
Nation. I look forward to answering the committee's questions
and serving as a resource as the committee's work continues
beyond this hearing.
[The prepared statement of Asbel Montes appears in the
Appendix]
Dr. Benishek. Thank you, Mr. Montes.
Mr. Leist, please go ahead.
STATEMENT OF VINCE LEIST
Mr. Leist. Thank you.
Chairman Benishek and Ranking Member Brownley, on behalf of
the American Hospital Association's nearly 5,000 member
hospitals, health systems, and other healthcare organizations,
I thank you for the opportunity to testify today.
I am Vince Leist. I am president and CEO of North Arkansas
Regional Medical Center. We are a county-owned facility that is
operated by a separate 501(c)(3), a not-for-profit
organization, serving the comprehensive healthcare needs of
rural communities of four counties in north-central Arkansas.
Like every community in America, we are proud of the men and
women who have served our great Nation, and we are honored to
care for them in their time of need.
America's hospitals strive to ensure patients get the right
care at the right time in the right setting. We have a
longstanding history of collaboration with VA and are eager to
assist the Department and our veterans in any way that we can.
However, hospitals' continued inability to obtain a timely
payment from VA and its contractors hinders access for care for
veterans who need non-VA services and undermines the ability
and viability of non-VA hospitals and the essential services
they provide to their communities.
We also are concerned about the process in which VA
processes claims. Medical records have been lost or unaccounted
for, leading to questions about the privacy of our veterans'
records. In addition, many veterans worry about their claims
that are not paid promptly or left unpaid completely, and they
are left in a difficult position of trying to get their claims
paid while they are battling illness. This is an untenable
position for both the hospital and for the veterans.
Last month, at a hearing before the House VA Committee, VA
Deputy Secretary Sloan Gibson acknowledged the lack of
timeliness in promptly reimbursing non-VA hospitals and
expressed his commitment to improve the payment process.
Hospitals and health systems welcome this commitment. However,
many non-VA hospitals have outstanding payments spanning many
months, some dating back years.
While North Arkansas Regional Medical Center is very
dedicated to serving the veterans in our community, we accept
each and every one who walk through our door. We have decided
against contracting with VA due to slow or no payment for
claims and the bureaucracy involved in getting reimbursement
for claims.
Since 2011, we have had 215 claims, totaling more than
$750,000, that have not been paid by VA. We have attempted to
work with VA to resolve these claims. However, those efforts
have resulted in long periods on hold to speak to VA
representatives, limitations on the number of cases that can be
discussed in any one particular phone call, and, once again,
countless lost medical records.
In addition, according to data from the Arkansas Hospital
Association, more than 4,400 claims, many dating back 3 years,
totaling more than $24 million, are currently owed 60 hospitals
in the State of Arkansas. In March, VA reported a national
backlog of more than $878 million in delayed payments for
veterans' emergency medical services delivered by non-VA
providers.
Even though our hospital has not been paid by VA for
services going back 4 years, we continue to provide care for
the veterans in our communities we serve. However, continued
lack of prompt payment and further reductions in Medicare and
Medicaid reimbursement would force our hospital and many other
hospitals across this country to reduce or eliminate services
offered to patients, resulting in reduced access to care for
the entire community.
To help address this problem of prompt pay, the American
Hospital Association recommends that VA do:
One, review claims as soon as practicable and, after
receipt, determine whether they are proper. When a claim is
determined to be improper, the Department should return the
claim to the hospital as soon as practicable but no later than
7 days after the initial receipt. VA also should specify the
reasons why the claim was improper and request a corrected
claim.
Two, pay claims within 30 days of the receipt of a proper
claim.
Three, make interest payments to hospitals when claims are
paid outside of this 30-day window.
And, four, Congress should require VA to develop a metric
to measure effectiveness of the claims processing, including
soliciting feedback from non-VA providers. VA also should
report to Congress on a regular basis the information it
obtains from the effectiveness of this claims processing.
In conclusion, VA health system does extraordinary work
under very difficult circumstances for a growing and complex
population of patients. While the system is working to overcome
operational changes, America's hospitals are eager to assist
the Department and the veterans in any way that we can. The AHA
stands ready to work with the committee to ensure prompt
payment to non-VA providers so that hospitals can continue to
provide vital services to veterans and all of the patients in
the communities that they serve.
Thank you, sir.
[The prepared statement of Vince Leist appears in the
Appendix]
Dr. Benishek. Thank you, Mr. Leist.
Mr. Cook, you may begin.
STATEMENT OF SAM COOK
Mr. Cook. Good morning. My name is Sam Cook. I am president
of Superior Van & Mobility. I operate nine mobility dealerships
in four States: Kentucky, Indiana, Tennessee, and Louisiana.
I am president of and am here on behalf of the National
Mobility Equipment Dealers Association. NMEDA is a nonprofit
trade association which includes more than 300 highly qualified
mobility dealers representing the small-business community. We
specialize in modifying, selling, servicing specially equipped
vehicles so that people with physical disabilities can drive
safely and be transported on public roads in accordance with
Federal motor vehicle safety standards. I would first like to
say the NMEDA members are proud and honored to serve American
veterans, especially those with disabilities, who have
sacrificed so much for our country.
I want to thank the chairman and the committee for focusing
their attention on VA slow-payment issue.
However, this investigation should not come as a surprise
to VA. Over the past 5 years, NMEDA has attempted to work with
VA prosthetics department and the Veterans Benefit
Administration to help remedy these chronic slow-payment
practices of local VAs. Over that time, NMEDA has submitted
nearly 4,000 past-due invoices, totaling over $34 million. To
be fair, VA at times has assisted in getting past-due invoices
paid, but after 5 years the situation has not improved.
According to the Prompt Payment Act, a payment is due 30
days after a government agency receives a proper invoice. This
simply is not happening in most VA facilities. For example, a
mobility dealer in North Carolina was owed $247,000 from just
one VA facility that included 15 separate invoices, all past
due for an average of 150 days. A mobility dealer in Texas was
owed $295,000 from one VA facility that included 55 separate
invoices, all past due an average of 312 days. At one point, my
own company was owed a total of $645,000 from five different VA
facilities over four States, 68 invoices, all past due an
average of 396 days.
These are just a few examples. This is completely
unacceptable. Mobility dealers are small-business owners, and
they simply cannot afford to carry this kind of debt on their
books and pay suppliers and meet payroll.
It also bears mentioning that, in most cases, mobility
dealers are not paid interest on these past-due invoices.
There are other payment process inconsistencies related to
how a dealer submits proper invoices to even qualify for
payment.
Finally, another VA inconsistency is VA has no criteria for
selecting automotive mobility dealers. Anyone can claim to be a
modifier without any training, appropriate facilities,
equipment, or accreditation and then bill the government.
The lack of any meaningful or timely effort by VA to
address slow payment, lack of conformity, and payment
submission policy, and having no measurable selection criteria
leads to a potential outcome of unsafe vehicles driven by
disabled vets, placing them, their families, and the driving
public at risk.
Based on NMEDA input, NMEDA has concluded that the reason
for VA not being responsive to this constant outcry is
multifold: number one, failure to communicate VA policy to the
field; number two, inconsistent enforcement of the policy;
number three, understaffing at VA; and, number four, supplier
payment not being a VA priority.
Those of us that deal with different VA facilities have to
deal with a different interpretation of the rules and policies
at each one. As the saying goes, if you have been to one VA,
you have been to one VA.
For the record, there is also evidence that this issue may
be worse than either reported or imagined due to reluctance to
speak out against VA in fear of losing future business. To be
clear, there are no written or verbal threats; the local VA
just stops calling or awarding business.
While $34 million may not seem like a lot in terms of
Federal budgeting, it is a huge amount to small-business owners
who have to bankroll VA's inability to manage the payment
process. We admit that not all VA facilities are guilty of slow
payment, and dealers appreciate those who pay promptly, but our
experience is the majority foster a culture of inconsistent,
unenforced, or ignored policy.
We respectfully ask Congress to demand VA ensure that
quality goods and services be delivered to our veterans and
those businesses delivering those be paid in a timely manner.
We all know our veterans deserve better.
Thank you. I would be glad to answer any questions.
[The prepared statement of Sam Cook appears in the
Appendix]
Dr. Benishek. Thank you, Mr. Cook. Thirty-four million
dollars sounds like a lot of money to me.
Dr. Migliaccio [continuing]. Is that how you say it?
Dr. Migliaccio ``Migliaccio.''
Dr. Benishek. ``Migliaccio.''
Dr. Migliaccio. Yes, sir.
Dr. Benishek. All right. Doctor, you have 5 minutes. Thank
you.
STATEMENT OF GENE MIGLIACCIO, DR.P.H.
Dr. Migliaccio. Good morning, Chairman Benishek, Ranking
Member Brownley, and members of the subcommittee. Thank you for
the opportunity to discuss VA's reimbursement efforts for non-
VA care providers.
I am accompanied today by Mr. Joseph Enderle, Director of
Purchased Care Operations.
There are three important points I want to share with the
committee this morning: First, we own the problem of aged
claims. Second, we are fixing the problem. And, third, we will
lean forward with continuous improvement and accountability.
VA's community care programs provide high-quality and
accessible care to veterans. To ensure that care is available,
VA understands the importance of complying with requirements of
the Prompt Pay Act and making timely payments to our partners.
Section 106 of the Veterans Choice Act required the
Department to transfer authority to pay for health care
furnished through VA community providers and the associated
budget to the Chief Business Office for Purchased Care no later
than October 1, 2014. VA met this target.
In just 7 weeks, we quickly realigned about 2,000
positions, of which 50 percent of those positions are veterans,
to the Purchased Care Office from the VISNs and our medical
centers. This realignment established a single, unified shared-
service organization responsible for payment functions and
centralized management, allowing us to leverage business
process efficiencies going forward.
VA has experienced tremendous growth in the volume of
claims from community providers since we started the
Accelerated Care Initiative in May of 2014. VHA has received 34
percent more claims from January 2015 through April 2015
compared to the same timeframe in 2014. We are making every
effort to ensure claims are processed timely. Our current
standard is to have at least 80 percent of our claims inventory
under 30 days old.
Processing timeliness is measured from the point the claim
is received to when the claim is processed and, as a result,
marked as complete. As of May 22, 2015, our nationwide
performance was 73 percent. And if our metric was aligned with
Medicare processing standards for other than claims with no
impropriety, which is about 45 days, our performance would be
76 percent. As of today, we are processing clean claims within
22 days.
Claims received by VA without prior authorization is one
significant factor in the delay of claims processing. When
claims without an authorization are received from community
providers, our staff spends time to ensure those claims are
adjudicated based on the veterans' eligibility. Based on
regulatory and statutory authority, not all veterans are
eligible for community care in all situations. When claims are
denied, veterans are notified timely, along with the right to
appeal.
I want to describe what we are doing to better our payment
processes.
First, we are refining standard processes and performance
targets and monitoring to ensure processing activities are
performed and measured consistently across VA.
Second, to better process claims, we established the
Support Claims Processing Division in March of 2015. This
division was established to assist with processing claims when
sites have high turnover, we see a sudden increase in claims,
or need assistance with verification of claims. To address the
increasing inventory, more staff was recently added to the
division.
Third, the Chief Business Office established a contract to
add support staff to process claims at those sites with
significant inventories. Currently, 145 full-time employees and
contractors are on board at Support Claims Processing Division.
Over 40 more employees are expected to be onboard this month.
VHA also plans to hire up to an additional 220 full-time
employees.
Fourth, VHA is implementing technical fixes for issues
preventing claims from being processed in a timely manner. All
community care referrals require authorization. Without the
authorization, claims cannot be processed, delaying payment. In
some cases, authorizations are not entered timely in VA payment
system due to administrative process. This is a processing
issue we must resolve. We are working with non-VA care
coordination staff to ensure authorizations are entered before
a claim is received.
Finally, we are working with VA Center for Applied Systems
Engineering to standardize business processing to increase
efficiencies and reduce variation using Lean methodology. We
have also completed technical site visits to evaluate how the
current software design is meeting business needs.
We are finding better and more frequent ways to communicate
the status of claims processing timeliness with stakeholders.
Ongoing training is also being provided to community providers
on the resources available to address their information needs.
Our recent actions have had a significant impact on
processing volume. From January to May of 2015, VHA processed
almost 6 million claims, a 21-percent increase from the roughly
5 million claims processed January to May of 2014.
We are thankful for the work of our community providers and
their work in providing timely, high-quality care to fellow
veterans, and we thank you for that. We are working hard to
expedite payments and streamline our claims services in order
to make this an effective and efficient system for all.
Mr. Chairman, I appreciate the opportunity to appear before
you today. We are prepared to answer any questions you or other
members of the committee may have. Thank you very much.
[The prepared statement of Gene Migliaccio appears in the
Appendix]
Dr. Benishek. Thank you, Dr. Migliaccio.
I yield myself 5 minutes for questions.
Dr. Migliaccio, how long have you been on the job there at
VA doing this job?
Dr. Migliaccio. Sir, this is my fourth week.
Dr. Benishek. Yes.
This is not the first time that we have been at a hearing
where we several people have testified about how things are,
you know, in their perspective, and then we have had a VA
person come and give us a litany of all the great things that
VA is doing to improve the situation.
The fact that you make that statement and the fact that
what is going on with these folks over here is still going on,
it doesn't really jibe very well. Do you understand what I am
saying?
Dr. Migliaccio. Yes, sir.
Dr. Benishek. I hate to beat you up because you have just
been here for 4 weeks, right?
Let me just list a couple of the things here that distress
me, one of the things you said was, ``we don't have a
documentation for the claim sometimes due to the administrative
process.'' That was one of the things you just said. The
administrative process is a lot of the problem, Doctor.
One of the things that Mr. Montes mentioned was the 768
claims where they sent the documentation to VA. They have a
certified mail receipts that it was signed for by VA. And yet
VA doesn't seem to have the documentation necessary to pay the
claim, despite the fact that it was signed before by a VA
employee.
So what happened to those records? What is the story there?
You should have those claims. Somebody signed for it. Where are
they? Who is looking at them? Is it secure? You apparently
don't know, as far as I can tell.
Can you answer that question for me?
Dr. Migliaccio. Well, I thank you for the question.
I also thank the members of the committee and also Congress
for the Choice Act because it has allowed us to standardize our
processes and centralize.
And so, with questions such as where are the records, it is
difficult to answer that question. I can ask my colleague, Joe
Enderle, to answer. But when we are looking at the 150-plus
medical centers and CBOCs that we have----
Dr. Benishek. Well, let's ask Mr. Enderle. Maybe he has a
better idea.
Dr. Migliaccio. Okay.
Dr. Benishek. What is the story there?
Mr. Enderle. Thank you, sir.
We do recognize that we have some internal process issues.
Claims come in, paper claims come in EDI. And most of the time,
especially with inpatient claims, unauthorized claims, and Mill
Bill claims, we must have the clinical documentation to
adjudicate those claims.
Dr. Benishek. Yes, we know that. But you apparently have
them; you just don't know where they are. Where are they?
Mr. Enderle. Actually, when the clinical documentation
comes in, we scan those claims into our Fee-Basis Claim System.
Sometimes those claims are delivered directly to our file room.
Those claims are subsequently again scanned in our VistA
Imaging System.
We acknowledge that we have had difficulty in pockets of
the country where the processes aren't, you might say,
functioning seamlessly and timely. So we are addressing----
Dr. Benishek. 768 claims is a lot of claims. It is
thousands of dollars, I am sure, for these folks here.
I guess what I need and the problem that I always get with
this is, can I have you be the one responsible for coming up
with an answer of why these claims are gone? Who is going to
take responsibility?
The problem I have with VA is it is never anybody's fault.
There is nobody actually responsible, so----
Dr. Migliaccio. I will take responsibility.
Dr. Benishek. Well, then, what that means is that I want an
answer to this 768-claim business. The administrative processes
answer doesn't really wash very well.
Dr. Migliaccio. Yes, sir. We will work with our community
providers. If we can get the data, the details, we can start
doing the research.
Dr. Benishek. Well, I will expect an answer to that
question within a month then.
Now, the other question I have is, what do you think of
this idea of having a third-party person do the claims thing?
It seems like Medicare or Blue Cross does a much better job,
adjudicating these claims, millions and millions of claims at a
time. What do you think of VA contracting that service out?
Dr. Migliaccio. It is something to think about. We would
certainly take a look at--we could do a cost-benefit analysis
to see where it makes sense.
Dr. Benishek. Yes, okay. All right. Appreciate that.
Mr. Montes, do you think that would be a viable offer for
VA, to have them contract that claims processing out to
somebody that actually does it for a living?
Mr. Montes. Absolutely. I mean, we do it for the TRICARE
claims through Humana, so some of our Active Duty, their claims
are processed through a fiscal intermediary. So the precedent
has really already been set.
Dr. Benishek. All right. So there is an idea.
I will yield now to Ms. Brownley. Thank you.
Ms. Brownley. Thank you, Mr. Chairman.
Mr. Cook, I had a question for you. You mentioned VA
inconsistency and the lack of criteria for selecting mobility
dealers in your testimony. Can you elaborate a little bit more
and explain what you mean by this?
Mr. Cook. Sure.
You know, right now, you and I could open a mobility
business and register with the government. We just send our
paperwork in, nobody looks at us, and we are a mobility dealer
and we can do business with VA.
And the handbook that VA is going off of, which I have in
my hand, on the first page is dated October 30 of 2000. That is
October 30 of 2000. Several different administrations of both
parties have been through, so it is not an issue there.
Supposed to be updated by 2005.
And we have met with VA, and because technology has changed
in our industry, the nature of it, from being high-tech
vehicles that are being produced now, there have to be some
standards, so to know that the person has insurance, to know
that the person has 24-hour service, to know that the person
providing has facilities that are even ADA-compliant. And these
are things that VA does not ask for.
And we have gone to VA and they say that is a good idea,
but we are still here.
Ms. Brownley. So you have gone to VA; they have said it is
a good idea. But we are now in 2015. We are operating under
2000 standards that were supposed to be--or at least the
handbook--updated by 2005?
Mr. Cook. Correct. And when each year we go and we meet
with them, they say, ``Well, we are working on it. It will be
the next year. We will have you something.'' And it has just
been, you know, a slow process. It is supposedly in the
regulatory process at this point now.
But, again, veterans are still being--have the potential to
have unsafe vehicles out there that it not only affects the
veteran, it affects all of us on the road. When you take a
vehicle and you put a 300-pound wheelchair and a 200-pound lift
on the back of a Toyota Prius, which happens, the vehicle's
rear end goes way down and the front end goes way up. We have
all seen it at our local grocery stores. And that is an unsafe
practice.
Ms. Brownley. So you could provide some evidence of dealers
out there that are not modifying automobiles correctly for the
veteran that could be quite dangerous for them rather than
assisting them?
Mr. Cook. Yes, ma'am.
Ms. Brownley. Thank you.
And, Mr. Migliaccio, are you aware of this issue, that it
has been 15 years and VA still hasn't updated the handbook?
Dr. Migliaccio. I am not aware of the issue about the
handbook, but I am aware of the issue in terms of the durable
medical equipment that VA purchases.
Veterans Benefit Administration takes care of service-
connected veterans, and I believe Mr. Cook alluded to that in
his testimony. The non-service-connected veterans are handled
by the VHA through our prosthetics program.
We know that Mr. Cook and his team met with our staff at
VHA about 3 weeks ago. We know there are no outstanding claims
from the VHA side. We also know that, from a quality
standpoint, in terms of the request for VA to endorse one
association over another is something that many Federal
agencies just aren't in--it is not in our wheelhouse to do. So
what I can say is that I understand the issues that Mr. Cook
has, but within the VHA side and with our Business Office it is
a little out of our wheelhouse. But we can certainly work with
Mr. Cook.
Ms. Brownley. Thank you.
And, Mr. Cook, do you agree that there are no outstanding
claims?
Mr. Cook. No, ma'am. There are--I have three right here of
my own company. 9/25 of 2014 for $25,600. I have--there are
millions of dollars right now that are past due nationwide.
That is bizarre, to hear somebody say that there are not VA
claims out there right now.
Right now, the issue--the VBA goes through the prosthetics
to handle the service-connected veteran. They administer the
program. The service-connected vet is being taken care of by
the prosthetics department, which then sends the bill back to
the VBA for processing. So you have two different hands on the
program, which makes it very confusing.
So the prosthetics department approves it, sees it out, and
then it goes back to the VBA for payment. So they are always
pointing fingers at each other, saying, well, no, it is their
fault; no, it is their fault, we have sent it in. The mobility
dealer sends the invoice to the prosthetics department. They
sign off on it, then send it to the VBA regional office for
payment.
Ms. Brownley. Thank you very much.
My time is over, and I yield back.
Dr. Benishek. Dr. Huelskamp.
Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate the
topic of this hearing.
I have heard consistently concerns about a lack of prompt
payment. I would like to ask the doctor from VA, can you
describe how the Prompt Payment Act applies to VA and how
quickly you are required under that act to make payments?
Dr. Migliaccio. Yes, sir.
The Prompt Payment Act from 1982 states that Federal
agencies have an obligation to pay timely, within 30 days, and
there is a privity of contract between a Federal agency and a
provider.
In our case, we do pay interest on late claims. We pay
those----
Dr. Huelskamp. Could you provide for the committee how much
interest you paid on these claims in the last fiscal year?
Dr. Migliaccio. Last year, close to $200,000.
Dr. Huelskamp. What is the interest rate you pay?
Dr. Migliaccio. Well, I would have to get back to you on
that.
Dr. Huelskamp. Okay.
All right. What is the application of--or what is your
expectation for prompt payment for those that are not payments
that would not be covered under the Prompt Payment Act,
noncontracted providers, which is where I hear those complaints
at? How quickly do those get paid?
Dr. Migliaccio. Well, as I mentioned in testimony, we pay
our claims right now within 22 days, clean claims. Claims that
are pended, we----
Dr. Huelskamp. Twenty-two days of receipt of the claim or
processing of the claim, scanning of the claim? What is the
start of the claim with your statement?
Dr. Migliaccio. As soon as it is scanned into the system.
Dr. Huelskamp. Okay. Well, that is a good point.
I am looking here at a copy of a status report, or a
response to a request for a status update from one VA facility.
And they said, ``Please be aware''--it is of January 1, 2015--
``there is a scanning backlog of approximately 90 to 120
days.''
So, based on your statement, then, your definition, 22 days
is after 120 days, perhaps, before the claim is even scanned
in, and then the 22 days? Am I understanding that correctly?
Mr. Enderle. If I may address that, sir, we did check into
that issue. The large backlog with scanning that you are
referencing is actually scanning of clinical documentation. It
is not associated with scanning the claims. The claims are----
Dr. Huelskamp. Certainly you don't process the claim
without documentation.
Mr. Enderle. The claims, if they are preapproved,
authorized claims, outpatient services, we do not require the
clinical documentation to process those claims for payment. So
the outpatient, preauthorized claims, as long as it meets the
authorization requirements, it is in our system. We process
those claims. And those typically, as has been mentioned, are
processed within 22 days.
Dr. Huelskamp. So why would you send a provider--this is
basically an excuse of why they have been waiting months to be
paid. And, again, told them 90 to 120 days before you even
start the claim. Is this because they are a noncontracted
provider? Or what is the distinction between those two as far
as you handle them?
Mr. Enderle. Sir, we process the claims the same, whether
it is contract or noncontract. They come in electronically,
they come in paper, they are scanned.
If the claims require clinical review and clinical
documentation, that clinical documentation has to be scanned so
that we can review it. We acknowledge that there is a backlog
in scanning that clinical documentation. And you are absolutely
right; it does impact the processing of those claims associated
with the requirement of clinical documentation review. So we
have----
Dr. Huelskamp. I am a little confused, Mr. Chairman.
If you are not looking at documentation except in certain
circumstances--so you are paying claims without documentation,
even though we are hearing here you aren't paying many claims
on time at all--but you are saying--what percentage of claims
do you pay with absolutely no documentation? You are scanning
the documentation months after you pay the claim; is that what
you are telling the committee?
Mr. Enderle. At that one particular location, there is a
backlog in scanning that clinical documentation.
Dr. Huelskamp. So they paid thousands of claims with no
documentation?
Mr. Enderle. Outpatient, preauthorized services are paid
without clinical documentation, that is correct. The only
requirement of clinical documentation are for those claims that
are----
Dr. Huelskamp. Why are you scanning them in 3 months later,
4 months later, if you have already paid the claim? That is
your claim for the committee.
Mr. Enderle. Specific claims that require clinical
documentation are inpatient claims, emergency outpatient
claims, emergency inpatient claims. We require the clinical
documentation to adjudicate the point of stability, if an
emergency existed, and the length of stay that the veteran is
in that particular hospital.
Dr. Huelskamp. Well, your statement doesn't match with what
VA facility was saying.
And I will enter this in for the record for the committee.
Dr. Huelskamp. But, also, the entity was told to wait 60
days to even call in. I mean, is this actually occurring, that
you are saying, ``Well, don't even call us for 60 days''? Or
when you call in--another example--when you call in, ``We will
only let you discuss four claims on the same call, and then we
have to hang up on you.'' Is that actually occurring?
Mr. Enderle. That was occurring, sir. We acknowledge that,
as we took over, with the implementation of the VACA law, we
did go out to the sites, we met with sites, we did find
situations like this. When we discovered these situations, we
immediately stopped it.
In this particular case, we did reach out to the site. We
instructed the site that they are not to issue that document
you are referencing again. And we implemented processes to
ensure that when callers call in that they can resolve any
issues of the claims that they have on hand.
Dr. Huelskamp. I yield back, Mr. Chairman.
Dr. Benishek. Thank you, Mr. Huelskamp.
Mr. Takano.
Mr. Takano. Thank you, Mr. Chairman.
My first question for the panel, for anyone who wishes to
answer it: The Choice Act has led to a lot of rapid change at
VA, and I understand that claims for non-VA care have increased
by 34 percent over this time last year, and VA has consolidated
claims processing under the Chief Business Office.
Has the late payment situation improved since the Choice
program has been instituted?
I guess, Dr. Migliaccio, you might want to answer that
question.
Dr. Migliaccio. I will start.
It has improved. We have brought together--when you
centralize anything, it is going to take some time. And that
process is behind us now, and what we are starting to see is
some phenomenal traction, especially when you look at that we
are processing clean claims within 22 days. And that--we are
following the standards in the industry.
Mr. Takano. And a clean claim is a prior-authorized claim?
Dr. Migliaccio. Yes, sir.
Mr. Takano. Now, my colleague Mr. Huelskamp was asking a
line of questions about the scanning that goes on with the
medical documentation afterwards. Am I correct in--my
understanding is, from listening to you, Mr. Enderle, that that
scanning of claims or the documentation afterwards is for the
non-clean claims. Is that right, or am I wrong?
Mr. Enderle. Anytime that we receive claims associated with
inpatient stays, emergency admissions to emergency rooms or
emergency admissions, we require clinical documentations.
In addition, if we receive a claim that has not been
previously authorized, which is considered an unauthorized
claim or a Millennium Health Care Act claim, in that scenario,
we require the clinical documentation so that we can adjudicate
the claim and determine if we can pay the claim on behalf of
the veteran.
Mr. Takano. So for those first types of claims that you
described earlier, those could be preauthorized. It is just
that the inpatient hospital stays are of a different nature,
and do you have to get the documentation, the medical
documentation for that?
Mr. Enderle. Yes, sir. They could be preauthorized, and
that is what we of course encourage, is that when a veteran
shows up at a non-VA facility, if they have an emergency, we
encourage that non-VA facility to contact the closest VA so
that we can preauthorize that claim.
Mr. Takano. I mean, so the nonpreauthorized claims and
these other types of claims you mentioned, how much of the
delay is due to medical records being inoperable? I mean, you
are dealing with a lot of non-VA providers who have different--
I am assuming that all these records are coming in paper; that
is why you have to scan them. Is that right?
Mr. Enderle. That is correct. We try to work with the
providers to provide them information on the best way to send
those claims in.
Mr. Takano. And, as I recall, some of the hesitancy of VA,
when we were talking about moving toward non-VA care to address
the backlog, was this concern about the interoperability of
medical records with non-VA providers. I mean, that is what I
recall.
Is it reasonable to say that this is a significant part of
the problem in terms of paying late claims?
Mr. Enderle. Yes, sir, I agree. If we can receive the
clinical documentation with the claim, we can expedite the
processing of that claim.
We also have a couple initiatives we are working on with
working with providers themselves to turn that into an
electronic access so we can access their system, pull down
those clinical documents, so we do not have to mail the claims
back and forth.
Mr. Takano. Mr. Leist, you mentioned this issue of lost
medical records. And it is lost paper records mainly; isn't
that right?
Mr. Leist. Yes, sir. Thank you for the question.
Yes, it is lost paper records. But I have to reiterate
that, when we send records to VA for processing, they are sent
certified mail. So we know those records arrived. We are being
told----
Mr. Takano. I don't think the problem is that the--I mean,
I think the problem is also in the manpower or the personnel it
takes to scan those records. So they may receive them, but it
sounds like the volume of medical records is also the issue.
Is that true, Mr. Enderle?
Mr. Enderle. That is correct. And in the particular
location that Mr. Leist is referring to, we did identify
significant issues at that location both with vacancies and the
internal processes that they utilize to acknowledge and scan
those documents. There was----
Mr. Takano. So you could see there were some significant
administrative snafus at that particular site?
Mr. Enderle. At that particular site, that is correct. It
is not a problem that we experience----
Mr. Takano. Mr. Leist, do you have something more to add?
Mr. Leist. Mr. Takano, I appreciate the comment. We would--
I will speak for my hospital. Hopefully the other hospitals
that are represented by the American Hospital Association would
say the same thing. We would welcome electronic transmission of
records to VA. We would be very interested ----
Mr. Takano. I am very interested in trying to facilitate
that. And if we can get the funding--I don't recall if we ever
inserted that into the Choice Act. But that is a high priority
of my office, is to facilitate--I think non-VA care would be
highly facilitated between--if we were to get this
interoperability to work with all those providers.
Dr. Benishek. Thank you.
Dr. Wenstrup, you are recognized.
Dr. Wenstrup. Thank you, Mr. Chairman. I appreciate it.
Dr. Migliaccio, one question I have is, where is your
predecessor now? Still working within VA?
Dr. Migliaccio. No. I believe she retired, sir.
Dr. Wenstrup. Okay. Because there has been a pattern here
that we get new people when there have been issues that have
been difficult. And so I am wondering if there is a reason for
that, that you get somewhat thrown to the wolves in this
situation, but we get somebody that has only been there 4 weeks
to have to answer all these questions. It makes it difficult
for us and certainly for you, as well. But it is a pattern that
we have seen.
My next question is going to claims that were submitted and
signed for and what is the process for tracking down the person
that signed for that claim that came in and trying to find that
claim. Because they get a card back that tells them who signed
it. So do you have a process in place of trying to track down
the person that signed for the claim that seems to be missing?
Mr. Enderle. The claims are typically received in the main
mailroom at the facility. When those claims do come in at the
mailroom, that is typically when those are signed by certified
mail.
They are subsequently then delivered to the non-VA care
payment office, where they are scanned into our doc manager
system. Or if the mailroom for whatever reason believes those
medical records should be sent directly to the medical record
file room, they may be scanned into what we call VistA Imaging.
So we have identified an internal problem with that
process, and we are attempting to fix that issue.
Dr. Wenstrup. Yes, I would suggest that the person at the
mailroom that signed for that gets a signature for who they
turned it over to so there is some level of responsibility
here, rather than blaming a computer glitch or a scanner that
didn't work. Then you might be able to actually track these
claims. And that is a large number of claims that were signed
for and lost.
My last question is to you again, Doctor. Would you be in
favor of accepting bids right now from an outside source to
process their claims?
You talk about increasing the technology to do electronic
claims. There are a lot of people that are already doing it and
doing it successfully. And these gentlemen will tell you that,
because they submit those claims and they get their payment.
So will you take the lead for us on getting some bids? That
shouldn't cost us anything. And maybe we can start to begin to
assess whether this would be a good business move for everyone
involved.
Dr. Migliaccio. We currently have a request for information
on the street right now to look at a new system.
In terms of contracting out the entire process, we could
certainly do the cost-benefit analysis and see what makes
sense.
Dr. Wenstrup. Well, I think that would be part of it. You
know, you talk about the cost of a new system. How about the
cost of outsourcing it and actually getting the job done? I
think that is a component that we need to look at if we are
going to make a good, wise business decision that helps not
only our providers but our patients.
So I would hope that at our next meeting we have some of
those numbers that maybe some of the outside sources give us a
bid on that. And I would appreciate that.
Dr. Migliaccio. Thank you, sir.
Dr. Wenstrup. Thank you.
And I yield back.
Dr. Benishek. Thank you.
Ms. Kuster, you are recognized.
Ms. Kuster. Thank you, Chairman Benishek.
And thank you to all of you for providing services to our
veterans. We are grateful for that.
I think I want to follow up on the line of questioning my
colleague Mr. Takano started. But, also, just to comment on
this approach of a third-party vendor, I am not opposed to
that; I just don't know that that is going to solve the problem
unless we solve the issue of the electronic records.
And I think where this seems to be headed is that the
backlog--it is not a question of who signs for it in the
mailroom. It is a question of you are ending up with boxes and
boxes and boxes of medical records that aren't getting into the
system in a timely way.
So I want to follow up on that issue of electronic records.
And if I could start with you, Mr. Leist, in the private
sector, when you are dealing with a claims processing, how do
you transfer the records? And just walk us through what that
process looks like. I am going to assume it is not reams of
paper records.
Mr. Leist. Thank you for the question.
First, I would like to comment a little bit on the entire
process of submitting a claim. I have found, as I have compared
the preauthorization process for patients with VA system and
according to the commercial processes, VA system is extremely
cumbersome. And, often, as reported in a recent document that
was submitted to this committee, it requires the signature of a
department head in the area where this particular procedure
would be performed.
Also, there are many issues I would like to address with
the Veterans Choice Program.
But, to answer your question, we submit claims
electronically to many commercial providers. They pay us in a
timely manner. If there are claims that are not supported by
documentation, we can address those immediately and resubmit
those documents. The communication between our hospital and
commercial providers is open, it is active. We are not limited
to the number of cases we can address over a phone call. Their
claims processing people are available to us, which has
heretofore been very different with VA system.
Ms. Kuster. Well, I think we have an opportunity here. We
have a Secretary that comes from the private sector. He is
looking to make these kinds of changes.
And I think we can find bipartisan support to get us to the
place where we can meet that standard. And it sounds to me,
from the testimony from our VA representatives, that on the
preauthorized claims we are getting close to that commercial
standard, that the complication here is on the other types of
claims--emergency room, inpatient, et cetera.
So I will cut my questions short, because I just would like
to work with you all going forward to get us to this commercial
standard. I think this is reminiscent--I am in my second term,
but when we first got here and started having hearings about
literally warehouses collapsing under the weight of paper
records that were being kept in boxes Lord knows where--and I
think what we have to do is try to get VA to the 21st century.
And this is a clearly a place where there is room for
improvement.
I would like to work with VA and with my colleagues on the
other side of the aisle to get us to that commercial standard
so that, number one, our veterans are served best and foremost;
number two, our small businesses are paid in a timely way to be
vendors to our government and to our veterans; and, number
three, the taxpayers are served. Because this particular system
doesn't seem to be working for any of those three.
So thank you for your patience, and we will look to work
with VA to move forward on this.
Thank you, Mr. Chair.
Dr. Benishek. Thank you, Ms. Kuster.
Mr. Coffman.
Mr. Coffman. Thank you, Mr. Chairman.
Well, there is just a pattern here where I bet you 3 years
from now we will be holding the same hearing with the same
results, and the only difference is there will be a new
director who will have been there for 4 weeks. He will be here,
and he will be telling the same thing that you are telling us.
And when you have a culture that is so inbred where bad
people can't be fired, where the good people that fundamentally
care about serving our Nation's veterans become whistleblowers
and they are retaliated against by the system, and the only
people that come before this committee to represent the
Veterans Administration are the get-along, go-along folks that
are just good at answering questions but they are not good at
doing anything--and so, you know, there is one solution here,
and that is to outsource it by the people that professionally
do this.
I am a retired military person. I am in TRICARE. And
TRICARE uses third-party payers that efficiently, you know,
reimburse providers. And so it is not being done by VA, and I
can't imagine that it will be done, but we will make changes on
the margins, I hope, and, I guess, that is considered progress
here in Washington, DC
So, Mr. Migliaccio, there is a company in my district, AMR,
American Medical Response, and I think they were owed $10
million. Now the number is up to $12 million over 90 days. I
understand you are having--at least there are phone conferences
with them on a routine basis. But what plan would you suggest
to provide AMR with some resolution to their backlog of claims
at VA?
Dr. Migliaccio. Thanks for the question.
Sir, for the record, I wanted to state also, I am a retired
uniformed officer, too, Air Force and Public Health Service, so
I get TRICARE also.
And we will take a look at this, but I have to tell you----
Mr. Coffman. Well, we are both lucky.
Dr. Migliaccio [continbuing]. We are going to get this
done. That is why I came here. I came from Health and Human
Services. So I chose this path to be here to make a difference.
Mr. Coffman. Well, I hope so.
Dr. Migliaccio. Yes, sir. But we have been having
conversations with AMR, and I am going to let Joe handle it
because he's been closer to it and also done some visits on
site.
Mr. Enderle. Thank you for the question.
In response to the question, the ambulance reimbursement
process is very complicated. It also falls under different
authorities and regulations. We authorize ambulance transports,
which falls under Beneficiary Travel. And the ambulance
transports that are taken care of in Purchased Care are those
transports that are associated with unauthorized and Millennium
Health Care Act claims. Because of that, we have to meet the
regulatory requirements. We review those claims, we review the
clinical documentation, and then we must make a determination
whether we can pay those ambulance claims.
Believe me, we would like to pay all the ambulance claims
for all veterans, because we do appreciate the fact that they
are transporting our veterans and taking care of them. But, as
mentioned earlier in the testimony, not all veterans meet all
the eligibility requirements, and in order to make that
determination, we have to do a clinical and administrative
review.
Many of the veterans are not eligible under unauthorized
claims or service-connected veterans or non-service-connected
to veterans who have no means to pay. But we take extra steps
to ensure that those veterans' claims are reviewed thoroughly
to make sure that if they do meet all the eligibility and
regulatory requirements that we can pay those claims on their
behalf.
Mr. Coffman. Yes. And how can this problem be resolved so
that the claims for veterans' ambulance service are not held
hostage, waiting for records that are completely outside the
control of ambulance service personnel?
Mr. Enderle. We recently reviewed the processes associated
with unauthorized and Millennium Health Care Act claims. Staff
in the field have been informed that they could use the
ambulance report. If they can determine it meets, you know, the
stipulation that it was an emergency for a layman's
interpretation and the clinical documentation on the ambulance
report is sufficient, we are not requiring the facility
clinical documentation to adjudicate those claims. So we have
made a change in that process.
Mr. Coffman. And, Mr. Montes, what type of excuses other
than the ones that you discuss in your testimony are commonly
heard from VISNs when they are asked about past-due ambulance
claims? And, with your work directly with VA, have they given
you any idea or ideas on how they plan to resolve them?
Mr. Montes. So there is a twofold issue.
One is those transports that are done under contract with
VA, so they are more authorized. And when you are actually
speaking--usually there is just one individual at that local
facility that is doing them. So if something happens or they go
on FMLA, a lot of times the processing just stops until they
come back.
If it is unauthorized or it is going through the Fee Basis
unit for payment, we have heard every excuse. There is not
enough time, or there are too many claims; we don't have enough
people to process those claims. They don't call you back. They
are taking a lot of effort to try to allow you to do more than
four claims to check, but it is just--it is an insurmountable--
or it is the wrong VA, you need to send it to another VA, this
VA doesn't provide 911 service.
So the emergency benefit of it is one issue. The
nonemergent or the transports that are actually originating out
of VA facility is typically under authorized care, and that is
a different issue in itself.
Mr. Coffman. Thank you, Mr. Chairman. I yield back.
Dr. Benishek. Thank you, Mr. Coffman.
Dr. Ruiz, you are recognized.
Dr. Ruiz. Thank you, Chairman Benishek and Ranking Member
Brownley, for holding this hearing.
And thank you to the panelists for your participation.
Last Congress, I was proud to come together with committee
members in both chambers to streamline VA's payment processing
systems. As VA implements this centralized processing and
payment system for all VA fee-basis care, we must ensure that
the focus remain on the veterans, that inefficient
reimbursement does not hamper veterans' access to services,
make it harder for veterans to seek answers from VA, or expose
veterans to financial harm. In this vein, VA must make certain
that veterans are held harmless from any problems the agency
has paying its bills, which are certainly no fault of our
veterans.
A Vietnam veteran in my district, a good friend of mine,
who has been approved to obtain 100-percent fee-basis care for
more than a decade, still reports frequent delays in VA
payments to his providers. When unpaid by VA, these bills go to
collection agencies, which can damage the veteran's credit
rating and expose the veteran to stressful harassment from
collection agencies and to financial harm.
So, Mr. Migliaccio, in the interest of preventing veterans
from enduring similar struggles, what safeguards are in place
to prevent veterans from incurring financial harm, poor credit
ratings because of delayed VA reimbursements to fee-basis care
providers?
Dr. Migliaccio. Thanks. I will start.
We want to put some systems in place so it doesn't get to
where the veteran is harmed at all. So we want to start from
the front end, and that is in terms of developing really a
solid system. And I won't get into this now to take the time,
but I am going to focus on our people, and we are going to
focus on business processes, and I want to look at technology,
also, so we can prevent this from getting to our veterans.
Dr. Ruiz. Okay. So, in other words, you are going to
prevent it by improving----
Dr. Migliaccio. Yes, sir.
Mr. Ruiz [continuing]. Your reimbursements.
However, you have hundreds, if not hundreds of thousands,
of veterans out there who already have poor credit ratings
because of VA's fault and no fault of their own. So what are
you going to do about them?
Dr. Migliaccio. Well, I have looked at the issue, and I
have looked at the information that we have provided back to
your office. I don't know if it is--the extent of the issue is
there. It is not as severe as we think because our relationship
is really with the provider. And if a provider----
Dr. Ruiz. Time out, time out, time out.
Dr. Migliaccio. Yes, sir.
Dr. Ruiz. When you say it is not as severe as you think,
now, I know that you are thinking as an epidemiologist, and you
are looking at the big picture, and it is systemic-wide. But
for one veteran whose credit rating makes it a matter of
whether he can pay rent or not, it is severe.
Dr. Migliaccio. Yes, sir.
Dr. Ruiz. So, for those veterans, whether it is 1, 2, 10,
20, who are barely making ends meet, if you are not paying
their bills and they are getting poor credit ratings, they
could be evicted, and then you have just increased your
homeless veteran problem, right? So what mechanisms can you do
to remedy that poor credit rating?
Dr. Migliaccio. Well, one veteran being affected is one too
many. We have some situations in place right now. We will go on
behalf and work with our veterans. If this situation arises, we
will work with the providers that sent the bills so we can
adjudicate those claims quickly and check that out. We also
will write letters to credit agencies to clear up credit
reports for our veterans----
Dr. Ruiz. Okay. So I would like you to commit to working
with this one veteran so that we can use that as a case study
and you can demonstrate what you can do not only for this
veteran, for the other veterans.
The other issue that I want to touch on is that I am very
concerned about what just transpired here. Mr. Cook said that
there are millions, if not billions, of dollars left unpaid,
and, prior to that, you had said that there are no outstanding
claims. So there are some serious discrepancies between what
Mr. Cook said and what you are saying.
So if you don't identify a problem, you are not even going
to attempt to fix it. So if there are--and he can show you
examples of late payments. So what are you going to commit to
do to remedy and rectify this discrepancy?
Dr. Migliaccio. Well, I will definitely work with Mr. Cook,
and I will ask for the information that he has brought forward,
and we will see how we can work.
I did my research with the Veterans Health Administration
to ensure that there were no outstanding claims there. If there
are, I would like to take a look at them, because we are going
to fix that.
Dr. Ruiz. Okay. I will follow up with you and with Mr. Cook
to make sure that these different examples are handled in a
timely fashion so that we can get an example and maybe build
some trust with our new Administrator here that he can
demonstrate to us that things may change.
So this is going to be a trust exercise between you and
this committee.
Dr. Migliaccio. Thank you.
Dr. Ruiz. Is that okay?
Dr. Migliaccio. I am on.
Dr. Ruiz. Okay.
I yield back my time.
Dr. Benishek. Good. Nice job.
Dr. Abraham.
Dr. Abraham. Thank you, Mr. Chairman.
Well, certainly, we have two gentlemen that do business in
my State of Louisiana. And I appreciate the testimony of the
three of you, because, as Dr. Benishek alluded to his opening
statement, it takes moral courage to be here because of the
retaliatory that VA may or may not do. So, again, I appreciate
you three gentlemen being here.
Mr. Montes, you said that--and Mr. Leist--that you all had
sent certified mail and they were signed for.
Mr. Enderle, you are telling me you are 120 days behind on
scanning, which is fine, I guess, in a way. But the claims that
Mr. Montes and Mr. Leist are talking about are far more than
120 days, so hopefully they have been scanned in. But Mr.
Montes says that he checked today with his office and there is
still no record of those 768 claims. So I suggest that maybe VA
has a HIPAA compliance issue also here, because you are
responsible now for those medical records.
I guess my question--Mr. Montes, let me ask you first.
Based upon VA's written testimony, they indicate that many
providers submit duplicate claims. Can you explain why this may
be occurring?
Mr. Montes. And this is from experience that we have
regarding the duplicate claims.
There are a lot of times that you can actually submit--and
some of the veterans' claims you can actually submit
electronically, either through a clearinghouse--they let you
know you can send through a clearinghouse, but they will need
the medical records, so you will have to send a paper record
along with it. So, in our opinion, when we are actually doing
the audit and we see that there is a mass amount of duplicate
claims that we are getting, that that probably has something to
do with it.
The second thing is, especially with an authorized claim
that we are under contract with VA, a lot of times they want us
to send that via email to that contracting officer so they can
first approve the claim before you submit it into their
electronic system, which is the OB10 system. And then at that
point in time is when the clock really starts.
So it is--I mean, just to kind of give you an update on
that, there is a lot of that practice happening with the
contracting officer at the local VA. When you are contracted,
it is: Send us the claims first, let us review them to make
sure everything is correct, then put them into the OB10 system.
So then the clock actually starts at that point from the Prompt
Pay Act provision.
So there is probably a dual thing going there, Congressman.
Dr. Abraham. Okay.
And a quick followup to that, and I will get to Mr.
Enderle.
You indicated, Mr. Montes, in your statement that your
accounts receivables have doubled since 2014. Can you give me
some numbers?
Mr. Montes. Absolutely.
Probably about 2-1/2 years ago, when we actually started
this process, we were at about $1.2 million in aging
receivables in 180 days. And we worked diligently with VA, with
our local VISNs. We actually got it down the end of last year,
around September, October, to about $500,000 over 180 days. And
we were doing high-fives and having champagne because that was
exciting.
But ever since October, it has now doubled. We are back at
about $1.8 million now.
Dr. Abraham. Thank you.
Mr. Enderle and Doctor, I will ask you these questions. You
stated that the delay sometimes in processing is caused by the
preauthorization process. Now, I have been on the doctor end of
it, and I know that if a claim is not preauthorized it is
usually not paid.
And what these gentlemen here are telling us is sometimes
they are having to stay on the phone minutes, if not hours,
just to get a preauthorization. And I can assure you, there are
many, many times, probably the majority of the times, that you
can't wait to get a preauthorization on a CT, MRI, or something
of that nature but you have to take care of that patient.
Is preauthorization required for 911 claims?
Mr. Enderle, I will ask you that question.
Mr. Enderle. Thank you for the question, sir. Could you--I
didn't hear the last part of your question.
Mr. Abraham. Well, is preauthorization required for 911
claims?
Mr. Enderle. For 911 claims, where they call the emergency
room, the veteran would--it depends. If there is a contract in
place and the veteran meets the eligibility----
Dr. Abraham. All right, let's get past that. But you are
saying the answer is, then, at least some are needed to be
preauthorized----
Mr. Enderle. Yes, sir.
Dr. Abraham. Okay. Well, that negates the purpose of a 911
call to begin with. If you have to go through the
preauthorization contract, to get on the phone, reach somebody
that may or may not give you an answer, that you may wait 20 to
30 to an hour long, that negates the definition of
``emergent.''
Mr. Enderle. If we are talking about an inpatient stay,
however, they do have 72 hours to contact the local VA
facility.
Dr. Abraham. Yes, but no inpatients are 911 calls. These
are outpatients that are having a heart attack or a stroke or
some issue like that.
I am out of time, Mr. Chairman. I yield back. Thank you.
Dr. Benishek. Thank you, Dr. Abraham.
Well, I still have one more question I want to ask. And I
think, since we have one panel, if others would like to ask
questions, then we will try to give people an opportunity to do
that.
There are so many things that I want to get at. One thing
here that came up in some written testimony. Apparently, AMR,
American Medical Response, referenced $12 million in backlogged
ambulance claims. Mr. Boustany from Louisiana mentioned $878
million in emergency care claims.
[The prepared statement of Hon. Charles W. Boustany appears
in the Appendix]
Dr. Benishek. And a statement for the record by AMR said,
``We are often told that VISNs are out of funds appropriated
for ambulance services in their budgets and we will have to
wait until the next fiscal year to be paid for our claim.''
This can occur as early as the first quarter of the year.
Dr. Migliaccio or Mr. Enderle, how much money is currently
available in VA's non-VA care fund?
Mr. Enderle. The specific----
Dr. Benishek. Some people are being told that there is no
money in their budget to pay the ambulance; you will have to
wait till next year.
Mr. Enderle. Actually, that is a great question.
Dr. Benishek. So I am trying to figure out what is the
story with that?
Mr. Enderle. Yes, sir. Whenever a claim is authorized, the
obligation for the funds to pay for that authorization is
obligated up front. There should be funds available to pay
those claims.
Dr. Benishek. So you don't have any idea how much money
there is available in VA's non-VA care fund?
Mr. Enderle. It is substantial.
Dr. Benishek. Can you just get me that number in the next
month?
Mr. Enderle. Yes, sir.
Dr. Benishek. All right. Thank you.
The other question I want to ask is that, Mr. Montes, there
was this meeting, apparently, in August of 2014, where AMR--and
VA officials addressed some of the backlog issues. You guys had
a conversation about how things were going to get better, and
we are going to work on things, and you made some
recommendations and offers for collaboration and problem-
solving.
Did anything happen after that meeting and collaboration?
Did things improve? That is what the whole process we are
trying to figure out today is, can VA learn from you guys and
make things better. What has happened since then?
Mr. Montes. So this was a collaboration with American
Medical Response and Acadian Ambulance Service when we met in
Atlanta, Georgia, with the national VA facilities as well as
several representatives from the VISNs. It actually got
probably a little better. They started actually having phone
calls. They were trying to research, try to figure what things
happened.
But whenever VA Choice Act was implemented, things just
started to break down at that point. And my colleagues at
American Medical Response, even with their phone calls that
they were having every other week, it just seemed it was the
same information being given back to them.
Dr. Benishek. Rehashed.
Mr. Montes. So it started off good. It started off as a
partnership. And then it just kind of became one-sided at that
point, because then there was just a lot of inaction.
Dr. Benishek. Right. Right. That is the problem we have.
Ms. Brownley, do you have a question?
Ms. Brownley. I do. Thank you, Mr. Chairman.
It was said earlier, I think by Mr. Migliaccio, that you
have paid $200,000 worth of late interest payments. Was that
within the last year or within the last couple of years?
Dr. Migliaccio. Last fiscal year.
Ms. Brownley. This fiscal year?
Dr. Migliaccio. This fiscal year.
Ms. Brownley. So I just wanted to ask the other panelists
if you have received late interest payments on any of the bills
that have been resolved with you.
Mr. Cook. I don't believe so. I don't know that there is a
process. You know, once the form that is sent in for the
adaptive equipment on there, it is what the total is. You don't
want to restart the process again to go back and add interest.
Ms. Brownley. Yes.
Mr. Cook. So I don't know that our members know how.
I would like to clarify something that VA said about NGO-
certified programs. They do have those with service animals
right now. They do this on anything that VA doesn't have
specialty, that are specialized industries, like ours. And we
did not--sure, we would like for them to endorse our QAP
program, quality assurance program, but we had just asked for
basic criteria. We will settle for that.
Ms. Brownley. And I hear you on that and also believe that
something absolutely needs to be done.
Any late interest payments that you have received, Mr.
Leist?
Mr. Leist. Thank you for the question. No, we have not
received any late interest payments at all.
But I want to take just a moment to clarify something I had
in my testimony. I had stated that our hospital had decided not
to contract with the Veterans Choice Program. And the reason we
had done that was because we are not in the position, a small
hospital in northern Arkansas, to contract for additional bad
debt. In other words--and I want to state clearly that if the
process improves we will contract to do those services.
But I also want to say that we will never turn away a
veteran in our facility for any reason. So, until this gets
resolved, we will continue taking care of those veterans,
without question.
Ms. Brownley. Well, thank you for that, Mr. Leist.
Mr. Montes.
Mr. Montes. The main issue is with the Millennium bill and
with the unauthorized care to the emergency--when you look at
it, our company actually did an estimation for fiscal year----
Ms. Brownley. I was just wondering if you had received any
interest----
Mr. Montes. No, we have not.
Ms. Brownley [continuing]. Late interest payments.
Mr. Montes. No, ma'am.
Ms. Brownley. Thank you. Thank you.
Dr. Migliaccio, so who do you report to exactly?
Dr. Migliaccio. I report to the Chief Business Officer.
Ms. Brownley. To the Chief Business Officer. So is he, you
know, the person who is ultimately responsible for all of these
issues?
Dr. Migliaccio. Well, the Chief Business Office reports up
to the leadership over at VHA.
Ms. Brownley. So the Chief Business Officer reports to the
Secretary?
Dr. Migliaccio. No, reports to one of the under
secretaries.
Ms. Brownley. To one of the under secretaries. Okay.
So do you have some sense--well, let me go back on the
interest payment thing. So, if you are saying $200,000 of late
interest payments for this fiscal year, I don't know what the
formula is for late interest, but, you know, what is the common
denominator here? So how much of outstanding or late payments
have there--I mean, what is the number for that? So is it a
million dollars? So you have $200,000 of late payments. Can you
give me a sense of that?
Dr. Migliaccio. Without--I really will have to get back
with you on that. I don't know the interest rate and what it
was based on.
Mr. Enderle. If I could supplement his comments, the
interest payments are paid when the payment goes through the
system. So, on the back end, when FMS cuts the check, if it is
a contract payment, and only if it is a contract payment, would
interest be applied, because we have a contract in place.
Ms. Brownley. Okay. But I am just saying, if there are late
payments of $200,000, it is based on, you know, late payment to
vendors and the contracts that you have, and I am looking for
what that number is. Because, based on the testimony we have
heard so far, it seems like, you know, it is millions and
billions of dollars, and the $200,000 late payment just doesn't
add up for me. So I am just trying to sort of reconcile that.
Dr. Migliaccio, so, you know, you are new, and we recognize
that it is hard to come into a new position in 4 months and
truly get your arms wrapped around, you know, all of the
problems and how to resolve it. And I think it takes a little
bit more time than that.
But, you know, I am just curious, you know, to hear from
you when you think you will get your arms wrapped around the
whole problem and when you would be able to present, you know,
a full plan to the committee and a timeframe of which you see
success down the road. So can you give me just a little bit of
a sense of that?
Dr. Migliaccio. Well, in my--thanks for the question.
I mentioned before that I am framing the assessment that I
am doing right now in the new position looking at our people, I
am looking at all of our processes, and I am looking at
technology. I have kind of defined where are the areas that I
want to look at, and claims is number one. Number two on my
list is the Choice Program, and I want to work with PC3----
Ms. Brownley. Do you have a sense of how many more people
you need to hire?
Dr. Migliaccio. Yes. When we onboarded--we onboarded about
2,000 positions we received for the transfer from our VISN and
medical centers. It was really 1,982. We only have----
Ms. Brownley. Those were unfilled positions?
Dr. Migliaccio. No. Those are--those are the positions that
came over. Not all the bodies were in those positions. So,
currently, we have around 220 vacancies.
And I think, once we can get our staff hired, trained, and
motivated on the work that we have in front of us, it is a very
mission-driven organization----
Ms. Brownley. So how long would that take, to hire 220
people?
Dr. Migliaccio. Well, I am a little fast on how I approach
an organization, so I would like to see it done yesterday. But
I think it is going to have to take us a minimum of 3 months,
working through the personnel system, to bring people on board.
Ms. Brownley. So you believe by 3 months, though, you would
be able to hire 220.
Dr. Migliaccio. That is a goal. And I hope it is not a
stretch goal.
Ms. Brownley. I yield back, Mr. Chairman.
Dr. Benishek. Thank you.
Dr. Huelskamp, do you have any more questions?
Dr. Huelskamp. I do, Mr. Chairman. I wanted to follow up on
an earlier issue and try to understand the distinction from the
gentleman from VA, as far as authorized and unauthorized care.
Oncology, cancer care, is that generally preauthorized, or
it is after the fact? Because the instance that has been shared
with VA over a month ago that we are talking about, that was
for cancer care.
Dr. Migliaccio. Well, I will let Joe handle this. But if it
is--if VA is going to send a veteran out from one of the
medical centers into the community for care, we are going to
get a preauthorization and make that appointment.
Dr. Huelskamp. I would hope so.
Dr. Migliaccio. Yes, sir.
Dr. Huelskamp. But, again, this is--then, in that case, as
I would anticipate, it is preauthorized, and we are still
waiting back on the 120 days to scan the claim. And so--but
that was always for unauthorized care.
So do you know--I mean, you have had this complaint from us
for a month. I would presume it is preauthorized, then.
Mr. Enderle. If it is the oncology----
Dr. Huelskamp. Yes, sir.
Mr. Enderle [continuing]. It would be preauthorized, yes,
sir. And that claim for outpatient services should be paid
without any requirement for clinical documentation.
However, the clinical documents that there is a delay in
scanning at this location, we are working with the local VA
medical center medical records department to make sure that
we--and, in fact, we have moved some of our staff over there to
assist them with scanning that clinical documentation to catch
up with that backlog.
Dr. Huelskamp. That is what is confusing me. It is
preauthorized, so scanning has nothing to do with it, the
scanning delay. But that is what you told the oncology folks,
that that is the reason. So that was inaccurate, then?
Mr. Enderle. Based on what I saw in that document, that
would be inaccurate.
Dr. Huelskamp. Okay.
Mr. Enderle. They should be able to process the claim for a
preauthorized claim without clinical documentation if it was
for outpatient services.
Dr. Huelskamp. Okay. Well, we sent the issue to you weeks
ago, and I don't know if you ever scanned in our email to you
about it, but maybe that is the problem, as well. So we are
still waiting for you to respond, to respond to them, and still
maintaining with them somehow it is a scanning issue, but it
clearly is not, then.
So how soon will you have an answer for making certain
these veterans can still go to preauthorized oncology care
without having to get in a vehicle and driving a long ways? So
when will we get an answer for them?
Mr. Enderle. From what I understand, the answer to your
inquiry is going through concurrence at this time.
Dr. Huelskamp. Describe ``concurrence.''
Mr. Enderle. Concurrence, our leadership concurrence. Once
the response is concurred on, it will be sent to you.
Dr. Huelskamp. Okay. Describe that. Who is concurring in
this?
Mr. Enderle. We draft the response to your inquiry; then it
is routed through concurrence and released.
Dr. Huelskamp. The real issue, when will they get paid for
helping the veterans and providing the care that you
preauthorized?
Mr. Enderle. The paid part should have already been
processed. In other words, if they already invoiced us for the
oncology care, we received an EDI claim. That claim should have
been processed and paid already--within 22 days, on average.
Dr. Huelskamp. Okay. It has not. I mean, that is my
question.
Mr. Enderle. Okay.
Dr. Huelskamp. It has been more than 22 days since we
contacted you about that. So you should be paying interest,
significant amounts of interest, on that.
But, clearly, you don't know. It hasn't been paid that we
know of.
Mr. Enderle. We need to look into it to see what the status
of that claim is, sir.
Dr. Huelskamp. Okay.
And another issue, just trying to clarify and understand
the process. I have another issue with a doctor of
chiropractic, that you called him and said, hey, would you
treat this patient for us? So I presume it is preauthorized.
Mr. Enderle. Yes, sir.
Dr. Huelskamp. So, again, it is not a scanning issue.
They started treatments in September and still waiting. You
called him, said, hey, can you take care of him because it is a
long ways from Wichita.
So is this the case, again, that--not a scanning issue--it
simply is a payment problem in this whole section of
preauthorized care?
Mr. Enderle. It sounds to me that that is a payment
problem, yes, sir.
Dr. Huelskamp. Okay.
Thank you, Mr. Chairman.
Dr. Benishek. Mr. Coffman.
Dr. Abraham, any questions?
Dr. Abraham. Yes. Thank you, Mr. Chairman.
The three witnesses from the private sector, I am assuming,
with your testimony, that the fiscal intermediary such as
Medicare and the tracker used would be certainly better than
this system that we have now. Would that be a statement we
could agree with?
Mr. Leist. Yes, sir.
Dr. Abraham. Okay.
And I will go to you, Doc and Mr. Enderle, that we
understand, and I have no doubt, personally, that your heart
and mind is in the right place for our veterans. I think
everybody in this room and on this panel agree. But, again, we
are dealing with government bureaucracy. And I won't be quite
as nice, I guess, as Ms. Brownley as far as giving you guys
time to hire.
Why not take the $200,000 on interest--and we know in this
room it is going to be a lot more once that back money comes
in--pay all the claims, and then go back to the providers on
the unclaimed claims and maybe let them reimburse you?
We are talking about veterans that are getting--I have a
list here of veterans that are having negative credit ratings.
I would imagine--and you can correct me, Mr. Enderle, if I am
wrong--that the number of veterans that don't qualify for 911
services are very small compared to the overall.
Why not pay the claims, use some of this money we are
paying in interest, and then, if you do find an unclaimed claim
that does not qualify, so to speak, well, go to Acadian, go to
Cook, and then let them reimburse? But don't hold up millions
of dollars that these gentlemen are providing for our heroes,
trying to do the right thing, and they are getting left holding
the bag.
I have a surgical hospital in my district, as I have said,
that, to their disappointment, to their severe disappointment,
have had to stop servicing veterans. We wrote VA about it. I
have yet to receive any response. And this goes back a few
months ago that I have yet to get a response as to why this has
happened.
But, again, we go back--this is just such an unacceptable
procedure. I am just looking for some comments here.
Mr. Enderle, I will take yours.
Mr. Enderle. Thank you for the question. That is a very
good question. I wish we could just process the claim for
payment and issue the check on behalf of our veterans, who
deserve the best from us.
Because of regulatory requirements, we have to determine
eligibility criteria of that individual veteran who the claim
is submitted on. And that process requires us, based on
regulation, that if that veteran does not have preapproval or
preauthorization, that claim, in essence, becomes what we call
an unauthorized----
Dr. Abraham. Well, I understand the process, but is that
regulation dictated by VA itself? Is that the rule that VA put
in place?
Mr. Enderle. It is both regulation and statute. So it is a
requirement that we have to determine eligibility based on
those claims that had not been prior-authorized. That prevents
us, based on the eligibility, to make that lump-sum payment
that you are referencing.
Dr. Abraham. Well, perhaps we can work on that.
Mr. Enderle. Yes, sir.
Dr. Abraham. Okay.
Thank you, Mr. Chairman. I yield back.
Dr. Benishek. All right. Thank you, Dr. Abraham.
I just have one more question for--maybe Mr. Enderle can
answer it. I don't know if you can do it, Doctor.
But I just got some information that the non-VA care budget
for fiscal year 2015 was set at, $5.4 billion, but then
apparently VA withdrew $700 million from that to cover
hepatitis C medication that has become expensive for VA. We are
also told that is why VA is making the Choice Program the
default option for outside care.
Is that true? Anybody aware of that?
Mr. Enderle. I am not aware of----
Dr. Benishek. Are there any other deductions from this
account for other VA expenses that anyone is aware of?
Mr. Enderle. I am not aware of any other deductions.
Dr. Migliaccio. I am not either.
Dr. Benishek. So what I would like to get to, then, is what
is the money remaining in that non-VA care fund for the
remainder of the fiscal year? So that is the number that I am
expecting from you all within the next month, okay?
Dr. Migliaccio. Chairman, is that under the Choice fund?
Dr. Benishek. Well, no. No, there is the non-VA care
budget.
Dr. Migliaccio. Okay.
Dr. Benishek. And then, we have been told that the Choice
has now become the default non-VA care option because of the
diminished amount of this fund due to other expenses. And I am
just trying to find out if this fund is being used for other VA
expenses and making it more difficult to get outside care.
Dr. Migliaccio. Not to my knowledge, but we will check into
it, sir.
Dr. Benishek. Well, I understand that hepatitis C treatment
is becoming expensive, but we need to deal with that and not
cut back on this part of care, as well.
Thank you all for being here today. I really appreciate it.
It has been enlightening. I appreciate the providers' being
here today and, actually, as many have said, for your
willingness to be here today and take the heat from VA for what
you are doing. If you hear from them in a negative fashion, I
would appreciate hearing from you.
And I appreciate both your presence here today, Doctor and
Mr. Enderle. I know what kind of a situation you are in, but I
am trying to hold people personally responsible for what they
are doing here. Because, typically, we get great responses from
VA, but then 6 months later, nothing has changed and there is a
different person giving us a great response. So it is very
frustrating on my part. The accountability of individuals is
paramount here.
So thanks, all, again.
The subcommittee may be submitting additional questions for
the record, and I would appreciate your assistance in assuring
expedient responses to those inquiries.
Dr. Benishek. If there are no further questions, the panel
is now excused.
And I ask unanimous consent that all members have 5
legislative days to revise and extend their remarks and include
extraneous material.
Without objection, so ordered.
The hearing is now adjourned.
[Whereupon, at 11:35 a.m., the subcommittee was adjourned.]
APPENDIX
Prepared Statement of Asbel Montes
My name is Asbel Montes and I am the Vice President of
Reimbursement and Government Affairs for Acadian Ambulance Service, the
largest private, employee-owned ambulance service in the nation. The
Chairman & CEO of our company, Richard Zuschlag, founded the ambulance
service division in 1971 with eight Vietnam veterans. Today, we now
have over 4,000 employee owners, with over 400 of those owners being
military veterans.
I am honored to sit before you today to represent not only the
industry, but even more so, the veterans we serve.
Background
Prior to coming before you today, our company, along with American
Medical Response, the largest public ambulance provider in the nation,
and the American Ambulance Association have worked diligently with our
Congressional delegations, other healthcare stakeholders, the Veteran
Integrated Network Services (VISNs), as well as the national leadership
at the VA to assist, recommend and frankly demand that the VA's
internal processes be updated and modified to ensure that they are
fulfilling their intended purpose, but also not placing financial
burden on the men and women who have served our nation so selflessly.
Despite these efforts, we have not seen any significant positive
movement from the VA and therefore find ourselves here today.
For a real life look at the issue, please allow me to provide one
example that a veteran in Louisiana experienced who called 911 for
emergency medical care and transport in 2014. We filed a claim and
provided all necessary medical records and appropriate documentation
within 30 days to the VA. We sent this information via certified mail.
The VA signed for it confirming receipt five days later. Almost a year
later on March of 2015, the veteran appeared on two local TV channels
describing how his claim was still unpaid. He was subsequently
contacted by a VA representative on March 18, 2015, indicating that his
claim would be paid and he would receive notification. The claim was
finally processed and paid in April of 2015, over a year and 3 months
from the time the claim was originally filed.
There are many more examples just like this one that could be given
by providers and veterans alike across the nation, but suffice it to
say, the GAO report in 2014 which highlighted issues regarding
excessive claims processing times and paperwork requirements for non-VA
providers is absolutely correct. This problem is especially acute for
the majority of ambulance service providers that serve as the local 911
responders in their communities, who are prohibited from refusing
emergency treatment for any patient, regardless of payor source or
ability to pay. This failure to pay providers in a timely and accurate
manner puts providers in the difficult position of having to bill
veterans for emergency treatment, placing an unfair financial burden on
the veteran due to the lack of response, invalid denial or payment by
the VA.
Our previous efforts at addressing this issue have included
numerous inquiries sent from Congressmen and Senators in many states
and the responses from the VA have remained wholly inaccurate and
inadequate.
My colleagues and I are not ignorant to the magnitude that this
issue presents for the VA. However, after numerous offers of assistance
and requests for relief from the private and public sector, we have
seen very little change. In fact, our company, American Medical
Response, and many members of the American Ambulance Association have
seen a recent escalation of the problem with our accounts receivables
due from the VA growing in excess of $30M outstanding over 90 days.
VISN 16 has sent reports to our Congressional Delegates with a
number that would indicate improvement, but our data clearly indicates
the opposite. On May 14th of this year, we had yet another conference
call with VISN 16, specifically the Flowood, MS office and requested
that they provide us with all claims filed to them since 2012 in order
to reconcile our records with theirs. That audit, which was completed
on last Tuesday, indicated that they showed no record of 768 claims
which were sent certified mail with confirmation of receipt by the VA.
Solution
2The federal government has a responsibility to ensure that our
veterans receive the best healthcare we can provide. It also has a
responsibility to ensure they are not required to bear an unjustified
financial burden because the VA fails to pay non-VA providers in a
timely and accurate manner. It is our recommendation that Congress
remove all claims processing for non-VA providers from the Department
of Veterans' Affairs and place it with a single Fiscal Intermediary,
providing guidelines and policies to address the issues stated here
today. This step would ensure consistency, efficiency and expertise in
personnel as well as sufficient dedicated resources to process claims
timely. Several other government programs, including Medicare and
Tricare, utilize this strategy successfully. Please note that time is
of the essence.
Thank you for giving me this opportunity to provide information and
to serve those who have sacrificed so much for our nation. I look
forward to answering the Committee's questions and serving as a
resource as the Committee's work continues beyond this hearing.
______
Prepared Statement of Vince Leist
On behalf of the American Hospital Association's (AHA) nearly 5,000
member hospitals, health systems and other health care organizations,
and its 43,000 individual members, I thank you for the opportunity to
testify on the Department of Veterans Affairs' (VA) ability to promptly
pay non-VA providers and the challenges hospitals and health systems
throughout the country have faced in receiving payment for services
provided to our veterans.
I am Vince Leist, president and CEO of North Arkansas Regional
Medical Center (NARMC) located in Harrison, Ark. NARMC is county-owned
and operated by a not-for-profit health care system serving the
comprehensive health needs of rural communities in northern Arkansas
and includes a 174-bed hospital and three rural clinics. We also
provide hospice, home health, urgent care and ambulance services and
operate six primary care clinics. With 101 staff physicians and nearly
800 employees, NARMC is the second-largest employer in Harrison County.
Like every community in America, we are proud of the men and women who
have served our great nation, and we are eager to serve them. These
brave veterans are our neighbors, and as a small community, we know
them well and are honored to care for them in their time of need.
America's hospitals strive to ensure patients get the right care at
the right time, in the right setting. As such, they have a long-
standing history of collaboration with the VA and are eager to assist
the department, and our veterans, in any way they can, including
providing care through the Veterans Choice Program, the Patient-
Centered Community Care (PC3) program, direct contracting with the VA
and, of course, serving the urgent health care needs of our veterans as
they arise when there is or is not a contract with VA in place.
However, hospitals' continued inability to obtain timely payment from
the VA and its contractors hinders access to care for veterans who need
non-VA services and undermines the viability of non-VA hospitals across
the country and the essential services they provide to their
communities.
We also are concerned about the process by which the VA processes
claims. Medical records have been lost or unaccounted for, leading to
questions of privacy for our veterans. Unfortunately, there are no
prompt payment laws for care that is provided to veterans if the
hospital does not have a contract, and there is limited oversight of
how these claims are processed. In addition, many veterans worry about
claims that are not paid promptly or are left unpaid, and they are left
in a difficult position of trying to get claims paid, often while
battling illness. It is an untenable position for both veterans and
hospitals.
Below, I outline why the lack of prompt payment impedes access to
care for veterans and offer recommendations to address this important
issue to ensure that high-quality care is provided to veterans and our
communities.
Background On Veterans Choice Program
The Veterans Choice Program is a new, temporary benefit allowing
some veterans to receive health care from non-VA health care providers
rather than waiting for a VA appointment or traveling to a VA facility.
It was authorized under the Veterans Access, Choice, and Accountability
Act of 2014 and provides $10 billion for non-VA medical care to
eligible veterans until the required end date of Aug. 7, 2017. The
temporary program will end early if the allocated funds of $10 billion
are used prior to that date.
While we understand that the VA had an extraordinarily short
timeframe in which to implement the program, hospitals, as well as
veterans, have faced many roadblocks when attempting to provide and
access care under the program. These roadblocks have resulted in a very
small number of eligible veterans being able to access the program.
With our shared goal of ensuring that America's veterans receive the
care they need at the time they need it, the AHA in March provided the
VA with suggestions for improving the Veterans Choice Program with
respect to the mileage requirement, timely payment of claims and
contracting to provide care.
Lack of Prompt Payment Hinders Access to Care for Veterans
Non-VA providers have experienced and continue to face problems
obtaining timely payment from the VA and its contractors. This hinders
access to care for veterans who need non-VA services and is a
disincentive for non-VA hospitals to either participate in the Veterans
Choice Program, the PC3 program or to contract with the VA to provide
healthcare services to veterans.
Last June, a witness from the Government Accountability Office
(GAO) testified at a House Committee on Veterans' Affairs hearing on
claim-processing discrepancies that delayed or denied payments for
health care provided by non-VA providers. According to GAO, these
delays or denials create an environment where non-VA entities are
hesitant to provide care due to fears they will not be paid for
services provided. In addition, a March 2014 GAO report found a non-VA
hospital often either received no response after claims were sent to
the VA or experienced lengthy delays, in some cases of years, in the
processing of their claims. The hospital had approached the VA to try
to discuss ways to improve the claims process, but those efforts were
unsuccessful.
Last month, at a hearing before the full House VA committee, VA
Deputy Secretary Sloan Gibson acknowledged the lack of timeliness in
promptly reimbursing non-VA hospitals and expressed his commitment to
improve the payment process. Hospitals and health systems welcome that
commitment from the VA leadership; however, many non-VA hospitals have
outstanding payments spanning many months--and some date back for
years--so it is essential to work quickly to solve the problem of not
paying promptly.
NARMC strongly believes that we need to serve the needs of our
veterans. The closest VA health facility to NARMC is a small VA
outpatient clinic down the street from the hospital. The closest VA
hospital is 70 miles away, and the nearest non-VA hospital is 60 miles
away. NARMC regularly accepts patients who are seen at the VA
outpatient clinic but are too sick to travel to the VA hospital or any
other hospital. These veterans are referred to our hospital by the VA
outpatient physician. We also regularly see veterans who come to our
emergency room because they have an urgent health care issue. Our
mission is to heal, and while we wish we did not have to focus on the
financial responsibility of running a hospital, we must--that is the
only way we can keep our doors open. While we are very dedicated to
serving the veterans in our community, and we accept each and every one
who walks through our doors, we have decided against contracting with
the VA due to slow or no payment for claims and the bureaucracy
involved with getting claims through the payment process.
Since 2011, NARMC has 215 claims totaling more than $750,000 that
have not been paid by the VA. NARMC has attempted to work with the VA
to resolve these claims; however, those efforts have resulted in, among
other frustrations, long periods on hold to speak to VA service
personnel, limitations on the number of cases to be discussed per phone
call and lost medical records. In Arkansas, NARMC is not alone in not
receiving prompt pay for services it provides veterans. More than 4,400
claims - many dating back more than three years - totaling $24 million
is currently owed to 60 Arkansas hospitals that are non-VA providers,
according data from the Arkansas Hospital Association. Our elected
officials have attempted to assist us with this difficult situation,
but those efforts have had limited success. Additionally, in March, the
VA reported a national backlog of more than $878 million in delayed
payments for veterans' emergency medical services delivered by non-VA
providers.
Even though NARMC has not been paid by the VA for services going
back four years, our hospital continues to provide care for the
veterans in the communities we serve. However, lack of prompt payment
from the VA combined with continued reductions to Medicare and Medicaid
payments for hospitals are jeopardizing access to care for patients.
From 2010 to 2014 alone, Medicare and Medicaid payments for hospital
services were cut by more than $121 billion. In addition, government
programs continue to pay less than the cost of providing services to
their beneficiaries--underpayment by Medicare and Medicaid to hospitals
was $51 billion in 2013 alone. Lack of adequate and prompt payment is
particularly challenging for small and rural hospitals that already are
contending with challenges such as remote geographic location, small
size, limited workforce, physician shortages and often constrained
financial resources.
If the VA does not pay claims promptly and further reductions in
payments for hospital care continue, NARMC would be forced to reduce or
eliminate services offered to patients or seek assistance from already-
strapped counties in Arkansas. For example, our hospital offers life-
saving ambulance services to four counties in rural Arkansas with no
support from tax dollars, but those services could be scaled back or
eliminated. Many hospitals throughout the country would have to make
similar decisions, resulting in decreased access to care for patients
and communities. We want to continue to provide essential health care
services to our communities, including our veterans, but will not be
able to do so without the proper resources, including prompt payment
from the VA.
Recommendations to Ensure Prompt Payment
As required by the Veterans Access, Choice and Accountability Act,
the VA must establish a nationwide claims processing system to receive
requests for payment and to provide accurate and timely payments for
claims. However, an interim final rule implementing the law does not
set forth the timeframes within which the VA must review claims and
make payment. The VA and its contractors should commit to paying non-VA
hospitals in a timely manner for Veterans Choice Program services, as
well as other services provided to veterans. Specifically, the VA
should:
Review claims as soon as practicable after receipt to
determine whether they are proper. When a claim is determined
to be improper, the department should return the claim to the
hospital as soon as practicable, but no later than seven days
after its initial receipt. The VA also should specify the
reasons why the claim is improper and request a corrected
claim.
Pay claims within 30 days of the receipt of a proper
claim.
Make interest payments to hospitals when claims are
not paid according to the 30-day standard.
In addition, Congress should consider requiring the VA to develop a
metric to measure effectiveness in its claims processing, including
soliciting feedback from non-VA providers, and have the VA report to
Congress on a regular basis the information it obtains on the
effectiveness of its claims processing.
Conclusion
The VA health system does extraordinary work under very difficult
circumstances for a growing and complex patient population. While the
system is working to overcome operational challenges, America's
hospitals are eager to assist the department, and our veterans, in any
way they can. The AHA stands ready to work with the committee to ensure
prompt payment to non-VA providers so that hospitals can continue to
provide vital services to veterans and all of the patients and
communities they serve.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Gene Migliaccio, Dr.P.H.
Good morning, Chairman Benishek, Ranking Member Brownley, and
Members of the Committee. Thank you for the opportunity to discuss the
VA's reimbursement efforts for non-VA care providers. I am accompanied
today by Mr. Joseph Enderle, Director, Purchased Care Operations.
VA provides care to Veterans directly in a VHA facility or
indirectly through contracts, including contracts formed when providers
accept individual authorizations, or through reimbursements, such as
for emergency care. This mix of in-house and
VA Community Care provides Veterans the full continuum of health
care services covered under our medical benefits package. VA's care in
the community programs are designed to ensure high-quality care is
provided effectively and efficiently to Veterans.
As Deputy Secretary Gibson remarked to the full House Committee on
Veterans' Affairs at a hearing on May 13, 2015, VA understands the
importance of complying with requirements of the ``Prompt Payment Act''
and making timely payments to community medical care providers. The
organizational changes, implemented in Section 106 of the Veterans
Access, Choice, and Accountability Act of 2014 (Veterans Choice Act),
which consolidated payment of claims under centralized authority, serve
as the basis for further improvements in making prompt payments.
Section 106 of the Veterans Choice Act required the Department to
transfer authority to pay for health care furnished through VA
Community providers and the associated budget to the Chief Business
Office--Purchased Care (CBOPC) no later than October 1, 2014. VHA met
this target and quickly re-aligned more than 2,000 positions and over
$5 billion dollars in health care funding to CBOPC from the Veterans
Integrated Service Networks (VISN) and VA medical centers. This
realignment established a single, unified shared services organization
responsible for payment functions and centralized management allowing
us to leverage business process efficiencies going forward.
VA has experienced tremendous growth in the volume of claims
provided by community providers since implementation of the Accelerated
Care Initiative which began on Wednesday, May 21, 2014. VHA has
received 34 percent more claims from
January 2015 through April 2015 compared to January 2014 through
April 2014. Our current standard is to have at least 80 percent of our
claims inventory under 30 days old. VHA staff makes every effort to
ensure claims are processed timely. Processing timeliness is measured
from the point the claim is received to when the claim is processed,
and as a result, marked as complete. As of May 22, 2015, our nationwide
performance was 72.50 percent, and if our metric was aligned with
Medicare processing standards for other than ``clean claims'' (45
days), our performance would be at 76.15 percent. A ``clean claim'' is
a claim that has no defect or impropriety, such as a coding error.
However, when claims without authorization are received from
Community Providers , VHA reviews all authorities to ensure those
claims are adjudicated based on the Veteran's eligibility. Claims
received by VA without prior authorization is one significant factor in
the delay of claims processing.
Information on community care is available to Veterans on the VA
website as well as the Federal Benefits for Veterans, Dependents, and
Survivors booklet. Based on regulatory and statutory authority, all
Veterans are not eligible for community care in all situations. An
example would be when a claim is received for a non-service connected
Veteran who also is not enrolled in VA care. When claims are denied,
Veterans are notified timely along with their right to appeal. As
detailed later in the testimony, VHA staff are also reaching out to
Community Providers and providing resources to educate them on Veteran
eligibility and timely notification requirements.
Improvement Strategies
VA acknowledges that claims processing timeliness must improve. As
a result, we are in the process of refining and implementing standard
processes and performance targets, and monitoring to ensure processing
activities are performed and measured consistently across VA. This will
enable us to deliver exceptional customer service to Veterans and
Community Providers.
In an effort to better process claims, CBOPC established the
Support Claims Processing Division (SCPD) in March 2015. The SCPD was
established in the Denver location to assist with processing claims
when sites have high turnover, when sites receive a sudden increase of
claims, and to assist with verification of claims. To address the
increasing inventory and work the growing backlog, CBOPC identified a
need to add more staff to SCPD in Denver. However, available space was
not sufficient to add additional staff, so SCPD established a second
shift to better utilize existing space. VHA is currently in the process
of implementing second shifts at other claims processing centers across
the country. The new shift has the benefit to VHA of opening
recruitment to a pool of candidates seeking to work non-traditional
hours for the Federal Government.
Additionally, CBOPC established a contract to add offsite contract
staff support to process claims at those sites which have significant
claims inventories. The first task order was issued in May 2015 to
provide claims processing staff support to process 400,000 invoices,
with a projection to increase processing to 600,000 claims by the end
of this fiscal year. Currently, 145 full-time employees and contractors
are onboard at SCPD. Over 40 more should be added by the end of June
2015, with additional staff projected to be added to a night shift by
the end of September 2015. VHA continues to explore ways to add
resources to better comply with the Prompt Payment Act and ensure that
our community partners are well situated to continue providing care to
our Nation's Veterans. In compliance with the Veterans Choice Act,
approximately 2,000 positions were transferred from VISNs and VA
medical centers to the VHA CBOPC. VHA has advertised positions for
claims processing at over 75 different geographical locations and plan
to hire up to an additional 220 full-time employees. We are also
advertising an open-continuous Merit Promotion Announcement for Voucher
Examiners to include targeting special appointment candidates.
Currently, VHA is implementing technical fixes and process changes
for issues preventing claims from being processed in a timely manner.
All community care referrals require authorization. To obtain
authorization in an emergency care situation, a Veteran should contact
the closest VA medical center within 72 hours of admission to community
care. Without the authorization, claims cannot be processed delaying
payment processing. In some cases, authorizations are not entered
timely in the VA payment system due to the administrative process. This
is a processing issue we realize we must resolve. To address those
situations, we are working with non-VA Care Coordination Staff to
ensure authorizations are entered before a claim is received.
Many community providers submit duplicate claims, due to the fact
that their original claim was not paid in a timely manner. In an effort
to identify duplicate claims within the payment processing system,
software scripts were developed to identify the duplicates which will
reject duplicate claims, leaving the oldest claim in inventory for
processing.
VHA is continuing to find ways to improve our systems. Currently,
we are working with the VA Center for Applied Systems Engineering to
standardize business processing to increase efficiencies and reduce
variation using Lean methodology. Starting in July 2015, testing of the
standardized business processing will take place in VISN 19. National
employee performance standards are being developed to improve
accountability and performance. Lastly, a Centralized Call Center Pilot
is underway in VISN 16, with calls being answered by CBOPC staff in
Denver. This pilot has dramatically reduced customer service wait times
and abandonment rates. We have also completed technical site visits to
evaluate how well the current software design is meeting business needs
in order to implement corrective actions.
Another important aspect is our improved outreach efforts with
stakeholders. We are finding better and more frequent ways to
communicate the status of claims processing timeliness with non-VA care
providers, Members of Congress, and Veterans. Ongoing training is being
provided to community providers on the resources available to address
the provider accounts receivables reports, to include monthly calls
held with providers on account claim concerns. Later this year, we hope
to begin distributing quarterly bulletins to providers on claims
processing changes and issues. A future project could include
developing a claims status portal for providers to access claims status
information. Call Center staff will receive refresher training to
address unique community provider issues.
Process Improvement Results
Our recent actions have had a significant impact in processing
volume. From January 2015 to May 2015, VHA processed 5,988,117 claims,
a 21-percent increase from the 4,946,989 claims processed from January
2014 to May 2014.
VISN 16 is a strong example of improvement based on our recent
actions. In December 2014, 35.58 percent of claims were paid in under
30 days. In May 2015, 82.13 percent of claims were paid in under 30
days. At the facility level, in May 2015, 83.13 percent of claims in
the Southeast Louisiana Veterans Health Care System's inventory were
paid in under 30 days. This is a significant improvement from the 35.29
percent in December 2014.
Conclusion
In conclusion, VA strongly values its relationship with our
community providers. We realize the vital role they play in assisting
us in providing timely and high-quality care to Veterans. We are
working hard to expedite payments and streamline our claims services in
order to make this an effective and efficient process for all.
Mr. Chairman, I appreciate the opportunity to appear before you
today. We are prepared to answer any questions you or other Members of
the Committee may have.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[all]