[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                  MISSION CRITICAL: EXAMINING PROVIDER
                   RELATIONS DURING THE TRANSITION TO
                    VA'S NEW COMMUNITY CARE PROGRAM

=======================================================================

                             JOINT HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                AND THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      WEDNESDAY, FEBRUARY 12, 2020

                               __________

                           Serial No. 116-57

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]     

                    Available via http://govinfo.gov
                    
                               __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-995                    WASHINGTON : 2023                    
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                                 ------                                

                         SUBCOMMITTEE ON HEALTH

                 JULIA BROWNLEY, California, Chairwoman

CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking 
MIKE LEVIN, California                   Member
ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN, 
MAX ROSE, New York                       American Samoa
GILBERT RAY CISNEROS, JR.,           ANDY BARR, Kentucky
    California                       DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
                                 ------                                

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                 CHRIS PAPPAS, New Hampshire, Chairman

KATHLEEN M. RICE, New York           JACK BERGMAN, Michigan, Ranking 
MAX ROSE, New York                       Member
GILBERT RAY CISNEROS, JR.,           AUMUA AMATA COLEMAN RADEWAGEN, 
    California                           American Samoa
COLLIN C. PETERSON, Minnesota        MIKE BOST, Illinois
                                     CHIP ROY, 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, FEBRUARY 12, 2020

                                                                   Page

                           OPENING STATEMENTS

Honorable Chris Pappas, Chairman, Subcommittee on Oversight and 
  Investigations.................................................     1
Honorable Neal P. Dunn, Ranking Member, Subcommittee on Health...     3
Honorable Julia Brownley, Chairwoman, Subcommittee on Health.....     4
Honorable Jack Bergman, Ranking Member, Subcommittee on Oversight 
  and Investigations.............................................     5

                               WITNESSES

Dr. Kameron Matthews, Deputy Under Secretary for Health for 
  Community Care, Veterans Health Administration.................     7

Mr. David J. McIntyre, President and CEO, TriWest Healthcare 
  Alliance, Inc..................................................     8

Lt. Gen. Patricia D. Horoho, Chief Executive Officer, OptumServe.    10

Mr. William A. Dombi, President, National Association for Home 
  Care & Hospice.................................................    11

Mr. Erik L. Golnick, Co-Founder and CEO, Veteran & First 
  Responder Healthcare...........................................    13

        Accompanied by:

    Mr. Eric Frieman, Co-Founder, Veteran & First Responder 
        Healthcare

                                APPENDIX
                     Prepared Statement Of Witness

Dr. Kameron Matthews Prepared Statement..........................    37
Mr. David J. McIntyre Prepared Statement.........................    38
Lt. Gen. Patricia D. Horoho Prepared Statement...................    45
Mr. William A. Dombi Prepared Statement..........................    50
Mr. Erik L. Golnick Prepared Statement...........................    56

                       Statements For The Record

Health Net Federal Services, Inc.................................    59
Home Care, Hospice & Palliative Care Alliance of New Hampshire...    60

 
                  MISSION CRITICAL: EXAMINING PROVIDER
                   RELATIONS DURING THE TRANSITION TO
                    VA'S NEW COMMUNITY CARE PROGRAM

                              ----------                              


                      WEDNESDAY, FEBRUARY 12, 2020

             U.S. House of Representatives,
                            Subcommittee on Health,
      Subcommittee on Oversight and Investigations,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 2:04 p.m., in 
room 210, House Visitor Center, Hon. Chris Pappas [chairman of 
the Subcommittee on Oversight and Investigations] presiding.
    Present: Representatives Pappas, Brownley, Rose, Cisneros, 
Peterson, Lamb, Brindisi, Sablan, Dunn, Bergman, Bost, Barr, 
Meuser, Steube, and Roe.

 OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN, SUBCOMMITTEE ON 
                  OVERSIGHT AND INVESTIGATIONS

    Mr. Pappas. Good afternoon. I call this hearing to order. 
Pursuant to committee rule 4 and House rule XI, clause 2, the 
chair may postpone further proceedings today, and without 
objection, the chair is authorized to declare a recess at any 
time.
    Today's joint hearing of the House Veterans' Affairs 
Subcommittees on Oversight and Investigations and Health will 
examine community providers' experiences with the ongoing 
transition from VA's legacy community care programs and 
contractors to VA's new MISSION Act community care program and 
its new Community Care Network contractors.
    In recent months, community providers have been contacting 
congressional offices, including my own in New Hampshire, to 
express serious concerns about significant delays in obtaining 
payments from VA's contractors. We have heard about 
administrative burdens associated with resolving outstanding 
claims, difficulties in being added to the contractors' 
networks and VA's provider directories, and sudden and dramatic 
cuts to payment rates for certain types of care, particularly 
dental and home health care.
    In some extreme cases, local healthcare providers have 
simply stopped seeing veterans altogether because the financial 
and administrative burdens are too onerous. It is unacceptable 
that community partners would be forced to stop providing care 
to veterans because of bureaucratic errors or process problems 
with transitioning from legacy infrastructure. These issues are 
happening during the ongoing transition from the third-party 
administrators that helped operate the Veterans Choice Program 
to the new third-party administrators that will help operate 
VA's new MISSION Act community care program.
    With any transition, a certain number of bumps in the road 
can be expected; however, this is more than just a bump, and we 
have been traveling this road for a long time and we need to 
see some significant improvement. Community providers simply 
cannot afford to continue treating veterans without being 
reimbursed for those services in a timely fashion, and veterans 
simply cannot afford to have their care delayed or halted 
altogether. These frustrations are not new, but the 
implementation of MISSION Act to date has clearly not 
alleviated these long-standing challenges with community 
provider relations.
    In my home State of New Hampshire, community providers have 
now had to work with three different VA contractors in the past 
2 years, and many are still awaiting payment for services 
rendered. In one case, the New Hampshire Hospital Association 
estimates that 23 of its hospitals are awaiting payment for 
nearly $137 million in claims for VA community care, the bulk 
of which was delivered in 2019. Yet another example, Dartmouth-
Hitchcock Health System, which is my State's only academic 
healthcare system, estimates it currently has more than 5,200 
claims totaling more than $24 million awaiting payment by VA's 
contractors TriWest and OptumServe.
    Payments are not the only source of providers' frustration 
with the VA's community care program. As you will hear from one 
of our witnesses today, Erik Golnick of Veteran First Responder 
(VFR) Healthcare in Manchester, New Hampshire, community 
providers are often bounced back and forth between VA's 
contractors and staff at VA medical centers when trying to 
figure out why contractors can not locate prior authorizations 
for veterans that they have treated.
    I am also concerned about VA implementing and imposing what 
appear to be new maximum number of visits for alternative pain 
management care. The committee has asked VA to explain a letter 
that some veterans received recently which indicates that 
veterans may now receive a maximum of 28 visits total per new 
condition for services like acupuncture, massage therapy, and 
chiropractic services. To date, the VA has not responded to the 
committee's request for more information.
    At a recent event in my district, I met with a group of 
veterans who shared with me their experiences with acupuncture. 
These treatments have significantly alleviated their chronic 
pain and, in many cases, eliminated their need for narcotics or 
other pharmacologic treatments. This small business is owned 
and operated by a dedicated woman named Kathy Twombly. Kathy 
contacted my office last August to share the hurdle she has had 
to navigate to provide this life-changing care to her veterans. 
We worked with Kathy and her medical biller to highlight some 
of the technical coding issues and confusing authorization 
forms. The bottom line is that we should not be forcing people 
like Kathy to struggle with a confusing payment system time 
after time or to jump through hoops to provide this type of 
lifesaving care.
    Finally, I hope today to hear a little bit more from the VA 
about its new payment rates for home healthcare. The committee 
has heard recently from home health providers across the 
country who were taken by surprise when they began receiving 
payments under VA's new fee schedule for home health. In some 
cases, these providers are receiving dramatically lower 
payments for VA patients than they have in the past, seemingly 
without any warning. Some health agencies worry that they will 
have to lay off their staff or stop accepting veteran patients 
because of these sudden rate cuts. I would like to know more 
about these changes and what the VA may be doing to revise its 
fee schedule given the effect it could have on veterans' access 
to home health care.
    Veterans who have fought for this country should not have 
to face another fight when they return home to get the care 
that they have earned. Providers who stand ready, willing, and 
eager to care for our soldiers when their service ends should 
not face a complicated and inefficient bureaucracy that forces 
them to lose time, money, and eventually the ability to care 
for veterans at all. We can do better.
    With that, I would like to recognize the ranking member of 
the Health Subcommittee, Dr. Dunn, for some opening comments.

OPENING STATEMENT OF NEAL P. DUNN, RANKING MEMBER, SUBCOMMITTEE 
                           ON HEALTH

    Mr. Dunn. Thank you very much, Chair Pappas. It is a 
pleasure to be here with you, and also Chairwoman Brownley and 
General Bergman and all of our colleagues on the subcommittees, 
both of the subcommittees, Health and Oversight. Our joint 
appearance here is to signal the importance of today's topic.
    Almost 2 years ago, in June 2018, the MISSION Act was 
signed into law creating a consolidated and much improved 
community care program to serve our Nation's veterans, and 9 
months ago, on D-Day 2019, that program went into effect. Since 
then, the VA has been transitioning to a new Community Care 
Network, a set of contracts with new community care contractor 
added to TriWest, OptumServe, in certain regions, including my 
own.
    If we have learned anything in the face of 2014 access and 
accountability crisis is that the Department of Veteran Affairs 
cannot serve the veterans alone and in a silo. Strong 
partnerships with high-quality clinicians in the community are 
critical to providing the access to care that veterans need. 
They are also critical to ensuring that the VA healthcare 
system remains strong and viable as the veteran population 
shifts and the delivery of care changes.
    Moving forward, we want to ensure that the community care 
networks that the VA is using are robust enough to provide the 
level of care that veterans are entitled to under the MISSION 
Act. We must ensure that community care is provided in a timely 
manner without unnecessary bureaucratic processes that delay 
needed appointments. We must ensure that community care 
providers that we are partnering with are providing high-
quality, safe, and readily accessible care.
    To do this, we must ensure these providers are being 
appropriately reimbursed for their services, and we want to 
make sure that those reimbursements are timely and accurate. 
Those features have not always characterized the VA's community 
care programs in the past, which means that the VA, Optum, 
TriWest, all have a lot to do to ensure the veterans, the 
providers, the employees, and Congress that the Department is 
on the right track.
    I greatly appreciated the opportunity early this week 
meeting with Secretary Dr. Matthews, as well as with General 
Horoho, former surgeon general and Chief Executive Officer 
(CEO) of OptumServe, and Mr. McIntyre, the CEO of TriWest, 
earlier this week in preparation for today's hearing. The work 
that they are doing is not easy, but their sense of dedication 
in this mission is sincere, and I came away from conversations 
with them and also with providers, hospitals, and doctors back 
in my district, a very positive impression of how the MISSION 
Act is working in our veteran communities.
    I look forward to hearing this afternoon about how they are 
making sure that veterans are well cared for during this 
transition period and how the community care program that they 
are building may be high performance, stable, and fully 
compliant with the law that we all work so hard to craft. I am 
grateful to all of my colleagues who assisted on that and also 
to our witnesses for being here today.
    With that, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you, Dr. Dunn.
    I will now recognize Chairwoman Julia Brownley of the 
Health Subcommittee for 5 minutes.

 OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN, SUBCOMMITTEE 
                           ON HEALTH

    Ms. Brownley. Thank you, Chairman Pappas, for agreeing to 
hold this timely joint hearing on the VA's implementation of 
its new community care networks and the challenges community 
providers are facing as they navigate this changing landscape.
    Back in September, the Health Subcommittee held an 
oversight hearing to check in on initial implementation of this 
new program. At that stage, the MISSION Act community care 
program had only been operating for about 90 days and Optum was 
live at just nine sites. Here we are 5 months later, Optum is 
fully deployed in Region 1 and is continuing its work to stand 
up Regions 2 and 3 by the end of May. I believe they are now 
serving about 70 VA medical centers, with more to come.
    While your progress is to be commended, arguably, now is an 
ideal time to reflect on potential lessons learned and how 
those are being translated into actionable solutions. Arguably, 
and this is a little bit selfish on my part, as my district is 
in Region 4, but I am hopeful that veterans and providers in my 
district will experience the most seamless transition of all 
yet to come in the new Community Care Network (CCN).
    I know that many members of our subcommittees have not been 
in Congress long and have to remember the initial rollout of 
the Veterans Choice Program and all the challenges that 
veterans and community providers experienced during that 
period. I remember these all too well, and I certainly hope 
that the VA and its contractors have applied lessons from that 
experience to the rollout of the CCNs.
    In the interest of time, wanting to have the fullest 
conversation possible from the witnesses, I will yield back the 
remainder of my time. I do, however, think it is clear from the 
written testimony submitted for today's hearing that we still 
have a way to go to improve veterans' access to care and 
community providers. By no means should we be declaring our 
mission accomplished. I look forward to our discussion.
    I yield back. Thank you, Mr. Chairman.
    Mr. Pappas. Thank you, Chairwoman Brownley.
    I will now recognize Ranking Member Bergman of the 
Oversight and Investigations Subcommittee for 5 minutes.

OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER, SUBCOMMITTEE 
                ON OVERSIGHT AND INVESTIGATIONS 

    Mr. Bergman. Thank you, Chairwoman, and thank you 
Chairwoman Brownley and Chairman Pappas, for holding this very 
important hearing.
    The Veterans' Healthcare Eligibility Reform Act of 1996 
greatly expanded eligibility for VA healthcare when it 
authorized the VA to provide care beyond the traditional 
service connected and poor to include all other veterans to the 
extent appropriations were available. Since 1996, the VA has 
seen an influx of veterans from the recent wars and additional 
eligibility expansions. As a result, the number of enrollees 
for VA healthcare has increased nearly 190 percent, from 4.9 
million veterans representing 18 percent of veterans in the 
year 2000, to 9.2 million enrollees representing 48 percent of 
veterans in 2019.
    During this period, the VA has grown its in-house capacity 
to provide care, while at the same time relying on community 
care partners to augment VA care as it has for decades. As many 
of you will recall in response to the Phoenix wait time 
scandal, Congress established the Choice Program. Since 2014, 
the VA has consistently allocated approximately 20 percent of 
the VHA's healthcare funding for community care. The remaining 
80 percent is used to fund in-house care.
    The Choice Program was, however, inefficient. So during the 
115th Congress, then Chairman Roe undertook the daunting task 
of replacing the Choice Program and consolidating the VA's 
patchwork of community care authorities into a single program. 
The result of that work was the VA MISSION Act, which I was 
proud to support, as well as I know many of the members up here 
on the dais today were proud to support. On June 6, 2019, the 
new community care program went live. In the fall, the VA began 
transitioning to CCN, Community Care Network.
    I appreciate the opportunity today to discuss the VA's 
implementation of the new community care program, because 
providers and veterans in my district have voiced concerns that 
the transition between Choice and the CCN contract has not been 
smooth. For example, in early 2019, providers began 
transitioning from Health Net as the third-party administrator, 
or TPA, to TriWest as the bridge contract after the VA elected 
not to renew Health Net's contract. Around the same time, the 
VA awarded Optum the Region 2 CCN contract, and providers who 
wished to continue to serve veterans were, again, asked to 
transition from TriWest to Optum as Optum built its CCN 
network.
    I understand the VA needed to feel the gap that Health Net 
left and some frustration was unavoidable. As the transition 
continues, it will be important to maintain high levels of 
communication between the network providers and the care 
providers. When care providers are left uninformed and 
unconnected to the incoming network, they are more vulnerable 
to transition and credentialing issues.
    Dr. Dunn and I had a really good conversation with Dr. 
Matthews on Monday, and I respect her for acknowledging the 
communications deficiencies. I appreciate that Optum is a new 
VA partner, and it will take time to iron out any wrinkles. If 
the VA and the third-party administrator partners fail to 
adequately and clearly communicate with community providers, 
those providers will elect not to participate in the program, 
thereby denying veterans the care option. This risk is not 
unfounded, as many providers declined to participate in Choice 
when they were unable to get paid in a timely manner.
    I look forward to hearing what the VA and its TPA partners 
have learned about the past communications deficiencies and 
what is being done to improve communication and provider 
relationships today and in the future.
    Turning to the veterans' perspective, I have heard from 
veterans in my district that they are waiting 3 to 4 months 
before being told whether their community care request has been 
approved. For veterans in my district, many of whom live in 
remote areas and who face bitter cold and difficult driving 
conditions during the wintertime, having timely access to 
quality community care closer to home can mean the difference 
between receiving care or foregoing care.
    Optum is scheduled to deploy to Iron Mountain VA Medical 
Center on February 19, just a week from today. I recognize that 
both the VA and Optum have roles in the referral process, so I 
want to hear what improvements veterans in my districts should 
expect as it relates to processing community care requests and 
when they can expect those improvements to materialize.
    I thank everyone and our witnesses for being here today, 
and I look forward to their testimony.
    With that, I yield back.
    Mr. Pappas. Thank you very much, General Bergman.
    I would now like to introduce today's witnesses. This 
afternoon we will hear from Dr. Kameron Matthews, Deputy Under 
Secretary for Health for Community Care, and Dr. Jennifer 
MacDonald, chief consultant at the Veterans Health 
Administration. Next, we will hear from the VA's two community 
care contractors, and with us today are Mr. Dave McIntyre, 
president and CEO of TriWest Healthcare Alliance, and 
Lieutenant General Patricia Horoho, CEO of OptumServe. Finally, 
we are joined by two witnesses that will offer their 
perspectives and share community providers' experiences 
delivering care through VA's community care networks. Mr. 
William A. Dombi is the president of the National Association 
for Home Care and Hospice--thank you for joining us--and Erik 
Golnick and Eric Frieman are co-founders of the Veteran and 
First Responder Healthcare, which offers substance abuse and 
mental health treatment in several cities, including my 
hometown of Manchester, New Hampshire. Thank you for being with 
us.
    We will begin by recognizing Dr. Matthews for 5 minutes.

                 STATEMENT OF KAMERON MATTHEWS

    Dr. Matthews. Good afternoon. Chairwoman Brownley, Chairman 
Pappas, Ranking Members Bergman and Dunn, and members of the 
subcommittees, I appreciate the opportunity to discuss the VA's 
continuing success in implementing the new community care 
program via the VA MISSION Act of 2018. I am accompanied today 
by Dr. Jennifer MacDonald.
    This is a time of transformative change at the VA. MISSION 
Act implementation is succeeding and it has become part of our 
core business as we prepare to deploy additional benefits to 
support veterans and their families. On June 6 of 2019, we 
successfully launched the new Veterans Community Care Program, 
a cornerstone of the MISSION Act, and have authorized more than 
3.85 million episodes of care in the community. Veterans now 
have enhanced care options, and we are streamlining our 
processes and technology to make their experience of care even 
better.
    Timeliness of claims payment to community providers remains 
a top priority. I acknowledge that the growth of community 
care, including unauthorized emergency care and antiquated 
payment systems with many limitations, have led to a growing 
claims payment backlog. We receive more than 1 million claims a 
month, and while we can process that incoming volume, we need 
further transformation to attack the backlog that is now more 
than 2 million aged claims.
    This is a backlog that has accumulated since before the 
Choice Program, and I have been working tirelessly since taking 
this role to eliminate it. Our goal is to work down the claims' 
inventory by the end of this fiscal year. A new claim system 
was implemented late last year, which provides automation of 
authorized claims. Additional automation will be introduced 
this spring. We have developed business roles that streamline 
the manual processing of unauthorized emergency care claims, 
which comprised the largest portion of our backlog. Additional 
contract support, along with my staff, now use these roles.
    In addition, as more care moves to our Community Care 
Network, the VA's third-party administrators are able to pay 
claims on the VA's behalf and are doing so in a timely manner. 
We are committed to being an excellent partner to the community 
providers in our network. We have to get this right. However, 
when we do not get it right, we need to be transparent and fix 
the issue as soon as possible.
    In the beginning of this fiscal year, the VA implemented a 
new standardized rate structure for home health. This new rate 
structure ensured a more accurate and standardized 
reimbursement rate methodology that accounts for variations in 
services and locality costs. However, after feedback, we agreed 
that in some locations the change needed to be more gradual 
over the course of several fiscal years. We worked to mitigate 
the issues and we have loaded the new fee schedule in VA 
systems last week.
    As we continue to transition to these new networks under 
the CCN contracts, which I expect to be deployed across the 
first four regions this fiscal year, we need to ensure that 
veterans have a seamless experience and that we maximize 
opportunities for continuity of care. As a primary care 
physician, I hold this as the ultimate priority and, therefore, 
we are stepping away from industry standard in order to ensure 
a veteran-centric approach to this transition. Effective change 
management is, therefore, critical.
    Veterans in Regions 1, 2, and 3 who are in the middle of an 
authorized episode of care under the TriWest network will 
continue that care until the episode of care ends. With other 
payers, that care would instead abruptly end. For veterans, if 
additional care is needed, it will transition under the Optum 
network after, not during, the originally referred episode of 
care. This allows the veteran to continue her/his care with the 
providers with whom they have established a relationship.
    We know when we began implementing the MISSION Act, that we 
had the potential to make an enormous positive impact for 
America's veterans. Today, we have begun to demonstrate that 
potential. I am very proud of the future that we are building 
on behalf of veterans and their families, and sincerely 
appreciate these committees continued support.
    This concludes my statement. My colleague and I are 
prepared to answer any questions you may have.

    [The Prepared Statement Of Kameron Matthews Appears In The 
Appendix]

    Mr. Pappas. Thank you, Dr. Matthews.
    I will now recognize Mr. McIntyre for 5 minutes.

                 STATEMENT OF DAVID J. MCINTYRE

    Mr. McIntyre. Good afternoon, Chairman Pappas, Chairwoman 
Brownley, Ranking Members Dunn and Bergman, and members of the 
committee. Thanks for the opportunity to appear before you 
today on Lincoln's birthday to discuss issues related to VA 
community care. It is an honor for all of those of us 
associated with TriWest, from our nonprofit health plan owners; 
to university hospital systems; to nearly 3,500 employees, most 
of whom are either veterans or veteran family members; and our 
subcontractors, to be supporting Drs. Matthews, MacDonald, and 
the entire solid team at the VA as they seek to deliver on 
Lincoln's words uttered at his second inaugural address: to 
care for whom shall borne the battle and his widow and his 
orphan.
    Those words equally apply to both males and females, and 
the commitment of a grateful Nation to be resolved to meet the 
needs of those who have defended our freedoms are as poignant 
today as they were when uttered in 1865.
    For the past 6 years, we have been called on to construct a 
community care network the VA could rely on for the care that 
they needed to place in the community, to process and pay 
claims, and to deliver customer service support to veterans, 
providers, and VA staff. On December 7, 2018, to honor World 
War II veterans, we stepped up to take over the rest of the 
country for a while at the behest of the VA as they had to let 
another organization go that was responsible for doing this 
work.
    We will forever be grateful to the nearly 700,000 community 
providers across the country who answered our call and for whom 
we have now processed and paid more than 23 million claims for 
healthcare needed by veterans to an accuracy rate of in excess 
of 96 percent. Just 11 million of those have occurred just 
since the start of the MISSION Act, and we look forward to 
getting to our personal goal which is in the 99 percent range 
in the near future.
    With the exception of a challenge at the end of last year 
which jammed up nearly 400,000 claims, for which we are nearly 
finished with the processing and payment, and 10,000 Emergency 
Room (ER) claims that we in the VA are working through, we have 
been processing and paying claims within the 10 days that we 
committed to do in the former Health Net area. For an average 
of 16 days nationwide, as we said we would do.
    The care in which we have been engaged includes everything 
from making sure that the next veteran generation gets 
delivered to eye care, to cancer care, to healthcare services 
unique to female veterans, to primary care and mental health, 
and to transplants and everything in between. Due to those 
providers who answered the call, we return less than 2 percent 
of care requests for no network provider available.
    Mr. Chairman, you talked about Dartmouth. We had the 
opportunity to visit on that yesterday. Out of the 4,137 bills 
that they provided us, there are only 458 pending, of which 
only 130 are 30 days old and the oldest is in October. Since 
June 6, this privileged work now includes new urgent care 
benefit. As of today, there have been over 190,000 encounters, 
with more than 90 percent of this Nation's veterans having 
access to such care within 30 minutes of their home.
    We are humbled to have been selected to continue this 
privileged work in our native territory of the west under the 
CCN contract for Region 4, and we welcome Optum to this 
critical work, and we will continue to fulfill our commitment 
to have overlap in their markets as they stand up strongly at 
the side of the VA to deliver.
    With regard to the coming CCN contract in Region 4, we in 
the VA are engaged in a full team sport, just as we have been 
doing for the last 6 years. To ready ourselves for the next leg 
of the journey in this transformation, we are implementing new 
tools and processes, assessing what we will leave will be the 
demand for care and services, and charting the implementation 
journey, which we expect will deliver for veterans and for the 
VA and for community providers who we call on to support. That 
rollout begins with Montana and eastern Colorado on April 7, 
and will conclude in mid-July with the rest of the region.
    There is a lot going on. As some of you have indicated 
today, it is a challenge. There is a long roadmap and it is 
extensive embodied in the MISSION Act. It is a privilege to do 
this work, and we are confident in our ability to deliver.
    I would like to close, though, with a story from a veteran 
who we are all responsible for serving that got conveyed to us 
last week.
    I was in really bad shape physically and mentally, said 
Thomas. I am pleased to say that I have now gone 12 days 
without a seizure. I learned a lot. The doctors here have done 
more to help me with my physical problems than I have received 
in 20 years. I did not know there was a treatment for alcohol 
detox. Since being here, I recognize that I have been in denial 
about my alcoholism for 48 years. I was in a wheelchair when I 
came here 30 days ago. Yesterday, I was shooting hoops, and now 
I have hope.
    That is the promise of what you all have birthed and we are 
privileged to do at the side of the VA. We look forward to 
doing our part, we look forward to applying the lessons we have 
learned, and I look forward to responding to any questions that 
you might have. Thank you very much.

    [The Prepared Statement Of David J. Mcintyre Appears In The 
Appendix]

    Mr. Pappas. Thank you, Mr. McIntyre.
    I will now recognize Lieutenant General Horoho for 5 
minutes.

                STATEMENT OF PATRICIA D. HOROHO

    Ms. Horoho. Chairman Pappas and Chairwoman Brownley, 
Ranking Members Bergman and Dr. Dunn, and members of the 
subcommittees, I am Patty Horoho, CEO of OptumServe. On behalf 
of the more than 325,000 men and women of the UnitedHealth 
Group, we are honored to be part of this mission, to provide 
community care networks for Regions 1, 2, and 3.
    The veteran is at the center of everything we do. We have a 
long history of serving our Nation's military and veterans. Our 
mission is to deliver a high-quality provider network to meet 
the needs of our veterans, and we are dedicated to fulfilling 
that mission. I am pleased to report Optum is on track in 
fulfilling that mission.
    Thousands of veterans are utilizing our high-quality, broad 
Community Care Network. Providers are getting paid promptly. We 
are providing timely and responsive customer service, and we 
are continuously building and adapting our network and 
operations based on data and utilization trends.
    Central to our responsibility is delivering a network of 
high-quality health providers from which VA staff and veterans 
can choose. To build this network, we began by leveraging the 
1.3 million providers and 6,500 healthcare facilities in 
UnitedHealth network and Optum provider networks, but that was 
just the beginning.
    With the VA, we are identifying an adding preferred 
providers who have a history for caring for our veterans. Today 
in Region 1, our network includes more than 178,000 unique 
providers in health systems across more than 309,000 care 
sites, and taking a data-driven approach, we continue to evolve 
the networks across all three regions to meet the needs of our 
veterans.
    On December 10, we completed Region 1. Since then, taking a 
data-driven approach, we have expanded the network by more than 
25 percent, adding 35,000 unique care providers, over 62,000 
care sites. Central to the success of the program is the 
provider experience. This includes paying them promptly, which 
underscores that Optum is a reliable partner, thus increasing 
provider confidence and continuing to deliver for our Nation's 
heroes. As of today, we have processed more than 150,000 
claims, and we paid these claims in an average of 11.9 days.
    Another critical element is answering questions and 
resolving issues as they emerge. As of today, we have received 
35,000 calls to our customer service center from VA staff and 
providers, with an average speed to answer of 3.6 seconds, and, 
most importantly, we resolved more than 99 percent of the 
questions or issues on the first call.
    We also want to ensure providers have the information they 
need to participate in the Community Care Network. Our 
communications approach uses different channels, including 
proactive letters, calls, and in-person meetings. After 
providers join our network, we utilize webinars, in-person 
trainings, and virtual townhalls to train them on the new 
network. We provide regular updates, education materials, on-
demand videos, and the ability to upload and track their claims 
all online, and we are restless in our desire to do more. We 
are committed to identifying new and effective methods in which 
to communicate with providers.
    In conclusion, 7 months into healthcare delivery, veterans 
are getting care from our network, providers are getting paid 
promptly, and we continue to adapt and build our networks 
across all three regions in strong partnership with the VA and 
TriWest. We are equally committed to continue our open lines of 
communications and regular engagements with Congress, the 
veteran community, and our stakeholders. We share your 
commitment to ensuring this program delivers experience our 
veterans deserve. Fifty percent of our community care program 
staff are veterans, and I am a veteran. We understand why 
getting this right is so important.
    Members of the committee, thank you for what you do every 
day to support our veterans, and thank you for this opportunity 
to testify.

    [The Prepared Statement Of Patricia D. Horoho Appears In 
The Appendix]

    Mr. Pappas. Thank you for your testimony.
    Mr. Dombi, you are recognized for 5 minutes.

                 STATEMENT OF WILLIAM A. DOMBI

    Mr. Dombi. Thank you for the opportunity to submit 
testimony here today.
    The Veterans Administration's healthcare benefits for home 
base care present one of the most robust arrays of supports for 
care in the home. This shows a strong commitment in the VA to 
provide significant and unrivaled home base care opportunities. 
There can be no doubt that the VA is a leader in providing 
cost-effective, high-quality, and innovative home care 
services.
    While designing a package of home care benefits for 
veterans is an important step to meeting their healthcare 
needs, it is equally important that the benefits be implemented 
in a timely and effective manner. The transition to the new 
community care program demonstrates the proper implementation 
planning and execution can make a dramatic difference in 
delivering on the promise of home care services.
    At present, there is room for improvement. However, there 
is also time to learn from the lessons from the early stages of 
the transition to establish implementation improvements. In 
that respect, I will focus on the experiences in home care 
programs to date.
    There, the issues that have surfaced involved, one, 
confusing communications; two, securing an adequate supply of 
care providers; three, care authorizations for payment delays; 
and five, payment rate cuts. Each of these subjects are 
addressed in more detail in my written testimony, but I will 
touch on them briefly.
    Communications is a big issue always in healthcare 
administration. Our members of the association report ongoing 
difficulties in gaining an understanding of what is changing 
through community care, who is responsible for the various 
parts of the transition, and how the care authorization process 
and provider enrollment process is supposed to work. Today, it 
is near impossible to find the detailed information needed to 
determine what is required for an existing VA home care 
provider to qualify to provide services in community care. For 
veterans, determining how to access home care benefits is also 
a major challenge. We recommend that the VA initiate website 
revisions that provide for improved navigation and content that 
answer these and other basic questions.
    Due to changes connected to the transition to community 
care, many of the long-standing home care providers are now on 
the outside looking in, turning away perspective patients on a 
daily basis while waiting for months to complete a 
credentialing, contracting, and enrollment process long after 
the transition has started. Today, many months after the start 
of the transition, significant numbers of previously qualified 
home care providers are still waiting to requalify. One company 
alone reports over 250 locations on hold.
    We recommend that the VA consider revising the provider 
enrollment process to avoid a loss of access to care, improve 
the options available to veterans, and ensure that patient 
needs are prioritized over paperwork. The revisions could 
follow a path traveled by a number of State Medicaid programs. 
There, the transitions permitted beneficiaries to continue 
receiving authorized services from their existing provider for 
6 months or more. It was a grandfathering of existing home care 
providers while undertaking any desired credentialing and 
contracting, and maintaining existing payment rates for some 
designated period of time. It was heartening to hear that some 
of that is already now in process.
    This manner of programmatic transition secures near 
seamless experiences for patients and providers alike, without 
creating any significant difficulties for the benefit program. 
With respect to care authorizations, it has been a long-
standing problem with VA home care. Care authorizations 
continue in community care problems. Home care providers report 
ongoing difficulties in getting authorizations processed 
timely, sometimes waiting 6 months or more to start care. As a 
result, some home care providers report that they have stopped 
admission of any new VA patients.
    In the absence of care authorization, care cannot start 
putting the veteran at risk. We respectfully recommend that the 
VA take immediate steps to expedite home care authorizations. 
One approach is to rely upon the judgment of the professionals 
actually providing the care for that veteran and cover care 
when certified necessary by that attending practitioner.
    Payment delays do continue to abound. Our members report 
delays of multiple months. It has reached a level of concern 
that a number of providers are discontinuing admissions of VA 
patients. No business can carry receivables for an extended 
period of time, and home care companies operate on human 
capital with payroll due every week. We recommend that the VA 
establish a clean claim payment deadline. Failure to meet the 
deadline should require the payment of interest on the amount 
owing.
    Rate cuts, the chairman mentioned that in his opening 
statement. When payment finally arrives, it is not always a 
pleasant surprise. Home care providers report unilateral rate 
cuts to levels far below the cost of care with no explanation. 
In many instances, the rate cuts are retroactively applied. 
Cuts of this nature trigger lost access to care. Rate setting 
appears to occur behind the curtain, leaving patients and 
providers often in the dark. We recommend that the VA maintain 
a transparent rate setting process that is focused on real live 
care costs and a level of payment needed to ensure 
uninterrupted access to care. Again, it was heartening to hear 
from the VA that they have got something of that nature in 
process.
    In conclusion, we greatly appreciate the opportunity to 
provide the committee with the foregoing information. We stand 
ready to partner with the VA and its contractors to develop all 
necessary steps to ensure a viable home care program fully 
accessible to our Nation's veterans.
    Thank you.

    [The Prepared Statement Of William A. Dombi Appears In The 
Appendix]

    Mr. Pappas. Thank you for your testimony.
    I will now recognize Mr. Golnick for 5 minutes.

                  STATEMENT OF ERIK L. GOLNICK

    Mr. Golnick. Good afternoon, Chair Pappas, Brownley, 
Ranking Members Bergman and Dunn, and members of the 
subcommittees. Thank you for inviting Veteran and First 
Responder Healthcare to testify today regarding our experience 
as a community provider working with the VA and with third-
party administrators.
    As a former naval officer who suffered from post-traumatic 
stress and substance abuse issues, I am acutely aware of the 
importance of advancing and improving veterans' access to 
health, and the hard work that these committees do we sincerely 
appreciate. VFR Healthcare, along with our sister organization 
Strive Health, is a veteran-owned and operated organization 
that was founded to increase the access to and quality of 
outpatient, substance abuse, and mental health treatment for 
veterans, first responders, and their families.
    In June 2018, we entered into a partnership with the VA to 
enhance veterans' mental health and treatment to reduce 
suicide. Since then, we have been working together to advance 
and improve veterans' mental health and well-being. Through 
this partnership, we were able to successfully enhance 
veterans' access to behavioral healthcare. For example, 100 
percent of veterans referred to our programs have a scheduled 
intake within 24 hours.
    We are honored to be partnered with the VA and have had the 
privilege of working and providing behavioral health treatment 
services to veterans over the last few years. In doing so, we 
have had the unique experience of working with the VA and 
providing healthcare services to veterans through several 
different community care programs and transitions.
    As a veteran-run company, we are mission focused on 
ensuring that veterans and their families get the highest 
quality care they need in a timely and efficient manner. As 
such, we assume the administrative burden on behalf of the 
veterans to make sure that any issues with billing or 
authorizations are taken by us. Taking on the administrative 
burden for veterans is especially important in mental health 
and substance use treatment as these administrative issues can 
cause stress and anxiety for veterans at a time when their 
stability and structure in their lives could be life and death.
    Now, before discussing our experience and challenges we 
have had as a provider, I think it is important to mention that 
we are also in network with over 15 separate commercial health 
insurance companies and two State Medicaid plans. The 
challenges we have experienced with the TPAs are not unique and 
happen quite often with other health plans during periods of 
transition. It is our hope by illuminating these issues and 
providing some insight as a community provider, we can assist 
in making the Community Care Network more efficient and the 
transition to other regions easier. I will now go through some 
challenges we have experienced.
    First is a clear delineation of rules, responsibilities, 
and troubleshooting process. On multiple occasions and spanning 
several different categories, we have run into administrative 
issues that both the TPAs and the VA were unable to resolve. In 
these instances, we followed protocol, spoke with TPA 
employees, who informed us that the local VA was responsible 
for addressing these issues. We then spoke to the local VA, who 
then told us that it was the TPAs responsible for resolving 
these issues.
    In all these cases, we ensure that the veteran is still 
being taken care of. We are not going to let that burden affect 
them.
    Second issue we run into is the ensuring a seamless 
referral process. We have spent a considerable amount of time 
with our VA partners and the TPAs to understand the referral 
processes and potential pressure points. While the new CCN 
allows VA staff to refer veterans to community providers, in 
practice, there are several what we would call pressure points 
where the referral can either be slowed down or almost stuck.
    Third is an efficient and accurate uploading into the TPA 
system. A complete and accurate upload of a community provider 
to a payer system is critical to ensuring that proper referrals 
are generated, claims and payments are appropriately paid, and 
accurate information is provided to veterans and referring 
providers. Any issues with this upload present dire 
consequences to the community provider and significantly 
affects the care currently being provided, as well as the care 
coordination with the VA.
    Fourth, uniform claim submission and reconsideration 
policies. Claim forms which healthcare providers submit to get 
paid for services rendered are extraordinarily complex and 
comprehensive. As such, setting and adhering to uniform claims 
submission and reconsideration policies is paramount to the 
claims and payments that we are--that we can--we are able to 
resubmit and properly adjudicate them.
    In conclusion, we appreciate the opportunity to address the 
subcommittee today to assist the VA and TPAs in their 
collective mission to enhance the health and well-being of our 
Nation's veterans. We believe the Community Care Network is 
critically important to ensuring veterans can access necessary 
care in a timely manner. It is imperative that processes, 
systems, and control are in place so the VA, the TPAs, and 
community providers can work seamlessly together to enhance 
access to care for veterans.
    While community providers like us are bearing the brunt in 
the short term, they are not unique to the VA or the TPAs, and 
we believe they are solvable challenges. We are confident that 
the VA and TPAs will work diligently to resolve these issues. 
We believe the VA and the TPAs and community providers will 
work together efficiently as a team to ensure that veterans 
receive timely and adequate care.
    Chairs Pappas and Brownley, Ranking Members Bergman and 
Dunn, and members of the subcommittees, this concludes my 
statement. We would be happy to answer any questions any other 
members of the committee may have.

    [The Prepared Statement Of Erik L. Golnick Appears In The 
Appendix]

    Mr. Pappas. Thank you very much for your comments and to 
all the testimony that we heard from our panel. We will now 
turn it over to questioning, and I would like to begin by 
recognizing myself for 5 minutes of questioning.
    We just heard from a witness, a community provider, who 
talked about frustrations that they have seen with the system, 
bureaucratic issues that result in this kind of palpable 
frustration that I hear from so many providers in my district. 
Some of it comes down to a lot of this, which is that, you 
know, a provider is told to go to the VA and the VA tells the 
provider to go to the third-party administrator, and it is this 
circular loop that sometimes they can not get out of.
    I am wondering if I could hear a little bit from Dr. 
Matthews about the support that you offer to providers and how 
we can get all the parties together to help address some of 
these concerns and allow people to just get the bill paid and 
provide the care to veterans that they want to provide.
    Dr. Matthews. Sir, thank you so much for that question. I 
am in complete agreement, not only with our colleague on the 
panel, but with the intent behind your question. We do need to 
streamline this process. I like the language that was used, not 
only about claims, but also referrals and authorizations. There 
needs to be uniformed processes on how to do this.
    What we have adopted and actually have rolled out to all VA 
facilities is a purchased referral and authorization system, so 
that there can be communication with our partners in the 
community, that there can be even messaging, but also sharing 
of referral and authorization data, of even sharing medical 
records so that there is a streamlined approach to how 
communications occur more than anything. A lot of times, there 
is difficulties in finding the right partner. There is the 
finger pointing, as you notated as well too. We really are 
streamlining how those communications occur by just increasing 
the technology that is available. It is not a phone call, which 
is just an outdated format.
    I think the other piece that I think we are still 
recovering from through the Choice Program was the need for the 
TPAs under Choice to authorize the care, so there was often 
some decisionmaking on the part of the TPA, which was wholly 
unsatisfactory for the veteran, for the VA. I think even for 
the TPA, speaking on their behalf. Under these new contracts, 
the authorization, the referral information, the scheduling, 
everything that is veteran focused remains with the local VA. 
The facility is the one scheduling, the facility is the one 
authorizing that care, making those decisions. Our third-party 
administrator partners are there to bill the network and to pay 
the claims. That is more industry standard, and we hope that 
our partners in the community have appreciation for that 
simplification.
    We do need to have more consistency, admittedly, amongst 
our facilities on how they use the new Healthshare Referal 
Manager (HSRM) system and how they communicate with their 
providers, and we are providing that sort of training and 
capability so that it can be streamlined in every way possible.
    Mr. Pappas. How can we measure that over time? I mean, one 
of the concerns is, you know, you have cited some process 
improvements that I think could help the situation, but if we 
are not getting feedback from folks like Mr. Golnick, how do we 
know how we are doing? I guess, how do you stay plugged in to 
the provider community? How do you measure satisfaction, and do 
you have a tool that you could use for that?
    Dr. Matthews. It is a great question and one I was going to 
answer exactly the wording you used. We would like to have a 
greater sense of provider satisfaction. We have multiple 
surveys within the VA of veteran satisfaction, but actually, 
through our third-party administrators, the network is 
responsible for collecting provider satisfaction data so, 
therefore, we can actually take action and improve when these 
sort of shortcomings are still in place. I look forward to that 
data. We have not had it in such a comprehensive way 
previously. Again, one of the benefits of having strong 
partners here to help us implement that is that it can be 
uniform across the network, and then we are best suited to then 
act on it.
    Mr. Pappas. In the referral and authorization system that 
you mentioned, is this new? When was that implemented? You 
know, because I am hearing so much back home about claims not 
being processed in a timely fashion. You know, is there some 
kind of a breakdown in this particular system or is it----
    Dr. Matthews. No. Multiple systems have actually been 
rolled out over the fall. The referral system is purely the one 
where the VA provider enters a referral and authorization and 
it actually can communicate directly with the community 
provider, if they so choose to use it. It is a cloud-based 
format and they can sign in and read about the referral. That 
was fully deployed over the fall. Not every facility has been 
using it because it is actually meant to interact with the 
Community Care Network as opposed to other providers that we 
have contracts or relationships with. As the facilities have 
been deploying to CCN, meaning launching to either Optum and 
soon to be the newer network under TriWest, they will be using 
HSRM more.
    Mr. Pappas. Do you know how many providers are using it? 
Then my time is up.
    Dr. Matthews. Unfortunately, I do not, but I can get you 
that information.
    Mr. Pappas. I think that would be helpful to know. Thank 
you for your responses.
    I will now recognize Dr. Dunn for 5 minutes.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    I want to say my couple comments first, Doctor/Secretary 
Matthews, I was thoroughly impressed with the progress you have 
made. You hit the community care programs in such a short 
amount of time. I enjoyed our discussion earlier this week. We 
both know there are still areas that can be improved, but I am 
grateful for and reassured by your very obvious detailed grasp 
of those problems and your proposed solutions and, frankly, 
your professionalism as well.
    General Horoho and Mr. McIntyre, speaking as a community 
doctor who has cared for veterans in community care programs 
for decades, and I am a veteran, let me say that the early 
results of your implementation of your portion of the MISSION 
Act has been a breath of fresh air. I have spoken with a 
sampling of my doctors and my hospitals back home about their 
experiences, specifically since D-Day 2019, and each of them 
noted dramatic improvements.
    I also spoke this morning with the chairman of Duke 
University Department of Surgery, who happens to be a 
transplant surgeon. Prior to the MISSION Act, his veterans 
could not receive an organ transplant anywhere in North 
Carolina. They were forced to travel to Memphis, Minneapolis, 
or Pittsburgh repeatedly for these services. He happily 
reported this morning that these veterans are now being allowed 
to receive the care right there at home in North Carolina, in 
his case, at Duke. Further, that the relationship between Duke 
and the VA hospital, which is directly across the street, is 
better than ever.
    First, Dr. Matthews, I would like you to briefly share with 
the rest of the subcommittee, share your plans to address 
those--well, I think you actually did just now, actually, with 
Chairman Pappas--the addressing the authorizations. I think 
that is great. There are also some problems, however, in the 
urgent care area, hospice, there are little hiccups there, home 
nursing. Briefly, briefly just kind of reassure everybody else 
as you did me earlier this week.
    Dr. Matthews. Excellent question. Thank you so much, Dr. 
Dunn.
    What we have instituted honestly toward the end of the 
Choice Program, but our more comprehensive with the approach 
now is a concept of a bundled authorization, not a bundled 
payment the same way Centers for Medicare and Medicaid Services 
(CMS) pays for things in bundles, sorry for being repetitive, 
but that in referring for the care and placing the order for 
the care, the VA provider is acknowledging a package of care 
that could be associated with that. If you are referring for a 
hip surgery, we are authorizing the physical therapy that goes 
along with it, we are authorizing the follow-up visits, the 
prescriptions associated with it, the labs, the x-rays.
    Mr. Dunn. That was so key. I can not tell you how many 
times somebody is authorized to see me but not have a CT scan.
    Dr. Matthews. Yes. This is just commonplace in really the 
managed care space. In the VA, we now have these--these are 
called standardized episodes of care, or SEOCs we also call 
these. This is critical, and they are being fine-tuned for 
exactly the services you mentioned, Dr. Dunn----
    Mr. Dunn. I know they are. I wanted the other members of 
the committee to hear that, because we took a deeper dive in it 
individually.
    General Horoho, Mr. McIntyre, your great experience, I will 
say the credentialing still could use a little massaging there, 
but I think you are up to it. It looks like the easiest point 
of the problems that we still had remaining.
    I guess what I will do is I will close and I will say, I 
want to continue our collaboration. I want to continue this 
conversation and communication back and forth with the 
committee. We want to give each other feedback, and I will get 
my feedback from my veterans and my hospitals and doctors back 
home, but I need to have--we need to have all of us talking to 
each other about these kind of problems. I think after we have 
a year's worth of data under our belt, perhaps sometime this 
fall we could do this again, maybe September, if you would have 
the data ready by then if you can. I will humbly besiege 
Chairman Pappas and Chairwoman Brownley and General Bergman all 
to join me again up here and hear how things are going 1 year 
in. But so far, I am cautiously optimistic. Thank you very much 
for your efforts on behalf of our veterans.
    I yield back.
    Mr. Pappas. Thank you. I think that would be timely, you 
know, given the VA's indication that these 2 million aged 
claims will be dealt with by the end of the fiscal year. We can 
see how things are going there.
    I will recognize Chairwoman Brownley for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    Hello, Dr. Matthews, it is good to see you again, after our 
travels to the Dakotas. It sounded to me in your testimony that 
you understand now about these rate reductions around home care 
issues. It was very alarming when I heard Mr. Dombi, is it? 
Correct?--Mr. Dombi's testimony of these rate reductions and 
then, you know, charging these providers retroactively a lower 
rate. It sounds to me as though you recognize that, and maybe 
you could talk a little bit about how you are going to address 
it.
    Dr. Matthews. Sure. Excellent question and, really, I admit 
that this was a fumble on our part. The fee schedule is 
actually updated on an annual basis at the beginning of the 
fiscal year, but as our colleague Mr. McIntyre acknowledged, 
the fee schedule got out late. This will be corrected moving 
forward; however, then in the fee schedule, there were several 
errors. Those have since been corrected. The new fee schedule 
has been updated into our claims processing systems and we will 
be reprocessing all the applicable claims back to the beginning 
of the Fiscal Year at the improved and updated fee schedule. 
There is no additional work that the community providers need 
to do, no resubmitting of claims.
    Ms. Brownley. Okay. When you say the rates, there were 
errors, I want to hear from you specifically that they were 
reduced improperly.
    Dr. Matthews. I actually can not confirm that, ma'am. These 
were--this was a fee schedule that was created through several 
subject matter experts who were communicating with the field as 
well as, I believe, with some community providers. That is how 
they created the fee schedule. I can not necessarily confirm 
that they were in error, with the exception that they were most 
likely reduced a little too quickly from prior rates. They have 
been adjusted back to something more reasonable and accepting 
for our partners.
    Ms. Brownley. Well, that still remains a concern for me 
then because, you know, honestly, in the hearings that I have 
had in my subcommittee, you know, this silver tsunami that is 
moving through the VA, you know, a large cohort of veterans who 
are 70 years or older who are going to need, you know, in-home 
care. This is where veterans want to be is in their homes. They 
do not want to be in a nursing home. They do not want to be 
institutionalized. Quite frankly, by serving them in home, it 
is win-win because it is where they want to be and it is 
actually cheaper in terms of our resources.
    I want to make sure that, you know, the right incentive is 
there to provide in-home services, you know, throughout the 
country. If we are going to begin to reduce rates when the cost 
of care is increasing, it sounds to me that is going to 
diminish our supply, and that is a concern--that is a concern 
for me.
    I hope when you are looking at the rates, you know, that 
you are taking a hard look at regional costs and keeping those 
rates at a level where we can increase the supply, because the 
demand is going to be greater than the supply and I think we 
have to move in that direction.
    Dr. Matthews. Can I clarify one point on that fee schedule?
    Ms. Brownley. Sure.
    Dr. Matthews. These are only rates that we are adjusting 
that do not have applicable Medicare rates. Any other in-home 
services that have Medicare rates, we follow the CMS fee 
schedule. This is only when we need to create additional fees 
that CMS does not cover.
    Ms. Brownley. Mr. Dombi, based on what you just heard, can 
you tell me what you feel the impacts are?
    Mr. Dombi. The impacts to date have been essentially just 
access to care. I am wondering after hearing what I am hearing, 
you know, is this a deja vu for being the second child in the 
family. You know, perhaps it is home care services that was 
last out of the gate in terms of actions taken, because it 
seems that we have been bearing the brunt of some of the 
administrative actions and some of these little snafus that 
have occurred there.
    When I say second child, no, I do not need any 
psychological counseling. You know, I have weathered that storm 
and now identify with my grandchildren, who are the second 
child in their family. You know, home care has been a 
stepchild, but, you know, we can announce here today we are 
going to take over the healthcare world, so we will get the 
respect eventually.
    Ms. Brownley. Well, I hope the two of you will converse and 
talk and work this--and work this out.
    I have a very little time left, so one question, Mr. 
McIntyre, that I wanted to ask you. When you were in my office 
yesterday, you said mental health usage in the community has 
increased 400 percent, which was astonishing to me, quite 
frankly. My question, and very quickly because I have run out 
of time, is are those veterans who are receiving community care 
for their mental health needs, are they also getting the 
wraparound services that they would normally be aware of and 
accustomed to by receiving their mental healthcare within the 
VA? I think I have used my time, so maybe you can get back to 
me on the answer.
    Mr. McIntyre. Do you want it for the record?
    Ms. Brownley. For the record. I yield back.
    Mr. McIntyre. All right. The one thing that I would say, if 
I might, is that you all adjusted the access standards for 
mental health, among a few other things, in the MISSION Act. 
That is what drove the increase in demand going into the 
community, because it said to everybody involved in this 
process, folks need to be seen faster. There is a limit in 
supply sometimes, and that is why the elasticity of the 
community exists in these contracts, and that is where the 
increase in demand came from.
    Mr. Pappas. Thank you for your comments.
    I will now recognize Ranking Member Bergman for 5 minutes.
    Mr. Bergman. Thank you very much.
    You know, as we have the different entities here, in some 
ways, it is no different up on the dais here than it is for you 
at the testimony table. We are only going to be successful if 
we build relationships at all different levels across any 
potential boundaries.
    Mr. Golnick, I would like to just thank you for not leaving 
anybody behind and being a first responder. You are setting the 
standard. Others can emulate that.
    You know, Dr. Matthews, what are you doing to build 
relationships with providers?
    Dr. Matthews. Great question. We have built, over the past 
couple of years, actually, a provider engagement team within 
community care within our office. I admit that it has not 
necessarily been an audience that has a dedicated area for 
communication and information prior years where websites were 
not updated, but really, it is one of our priorities. Without 
our provider partners, we obviously could not provide these 
services to veterans. We are really looking to improve 
communications.
    We have more direct consultations available for providers 
to communicate directly with my staff. We have monthly webinars 
and trainings where they cannot only learning about our 
business operations, but also take a lot of the training that 
VA providers have. We emphasize suicide prevention and a lot of 
the other veteran-specific conditions, even the ones 
acknowledged under the MISSION Act. We are really doing as much 
as possible to hit a broad audience through available 
resources.
    In addition, myself and other leaders in my office, we are 
definitely communicating with different member associations. I 
am presenting at multiple different hospital associations, 
primary care associations, Association of American Medical 
Colleges (AAMC). We attend many conferences just to get out the 
language, the messaging around, really, VA's acknowledgement 
that----
    Mr. Bergman. I hate to cut you short because it is a long 
answer. You are obviously doing a lot of things. Remember, you 
know, communication is not what is said, it is what is heard.
    As you are communicating, I do not want to sound 
instructional here, but if you can receive feedback at the same 
time you are trying to communicate to see if your message is 
being heard in the way you intend.
    Also, kind of to piggyback a little bit on the fee schedule 
piece, Dr. Matthews, this is the type of situation that should 
be avoidable and negatively impacts the VA reputation because, 
not only are the veterans concerned, but the providers, as we 
saw prior to when you do not get paid and you do not know what 
is going on, that kind of destroys their confidence.
    For Dr. Matthews and General Horoho, I would like you to 
take this one for the record because it is a long answer but, 
you know, my office has received complaints that for some 
veterans, it is still taking months to process approvals for 
community care. With Optum going live in Iron Mountain in my 
district next week, I am asking your help to manage 
expectations there. How long should a veteran expect to take 
from the point of referral by VA to a community provider to the 
point of seeing the doctor in the community? I mean, should 
they expect that right away or will it take time to get there. 
Or if it will take time, how long? I mean, do you have any 
metrics or goals that maybe you see here you are today and 
where you are trying to achieve reasonable goals?
    Dr. MacDonald. Sir, we will take this for the record as you 
asked, but happy to communicate directly with you on this and 
engage your office, if you would like. We have briefed staff on 
our new referral coordination initiative which will take care 
of this. Urgent referrals, VA processes in 2 days and gets that 
care delivered. It is the routine referrals that you are 
addressing, and we would be happy to go deeper on that with 
you.
    Mr. Bergman. Yes. It is because it is about setting 
expectations and it is, you know, just getting those--you know, 
getting the answers.
    Mr. McIntyre, I know I have got about a minute left, but 
would you please elaborate on TriWest's demand capacity 
assessment process and how it informs TriWest's efforts to 
build its provider network?
    Mr. McIntyre. Yes, sir. Thank you for the question. We used 
a set of tools most recently to lay down the urgent care 
network for all of your districts across the country. 
Basically, what we do is we understand and chart out where 
veterans live, so the actual address of their rooftop. We look 
at the demand profile from each one of the VA medical centers 
wrapped around that population. Then from that, we figure out 
what the supply needs to look like for each of the specialties 
for which someone needs to see.
    We have been using this set of tools since after 9/11 when 
we built networks for the Guard in States like Idaho. We picked 
it up in the crisis in Phoenix. Then we used it for urgent 
care, and we are now--we have just finished the assessments 
with VA at the ground level in Region 4, and that is informing 
how we will set the network for Region 4 going forward.
    Mr. Bergman. Okay. Thank you.
    Mr. Chairman, I yield back.
    Mr. Pappas. Thank you, Ranking Member Bergman.
    I would like to recognize Mr. Lamb for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman. Thank you to all for 
being here. Especially thank you, Mr. Golnick, for coming all 
the way from New Hampshire. Good to see you again.
    The veteran's example that you gave in your testimony, it 
still had not been cleared up after almost a year of 
nonpayment. Was that an old TriWest claim or was that an Optum 
claim the entire time? I am sorry if I did not pick that up.
    Mr. Golnick. That was a TriWest claim.
    Mr. Lamb. Okay. We are hoping that with TriWest resolving 
those old claims in the next year, that that would be resolved 
along with the rest of them. Is that your expectation now?
    Mr. Golnick. I am not sure what our expectation is, to be 
frank. I am hopeful that we will get to a resolution, because 
in this example, we have the referral in hand that has been 
authorized, but no one knows from the TPA side or the VA side 
what to do next in order for the claims to be reimbursed 
properly.
    Mr. Lamb. Okay. I know from talking to you, Mr. Golnick, 
that you operate in Pennsylvania as well as New Hampshire?
    Mr. Golnick. That is correct, sir. Yes.
    Mr. Lamb. Have you seen similar issues with the TPAs and 
getting paid on time in Pennsylvania or is there a geographic 
difference or is it the same?
    Mr. Frieman. We have actually seen, in Pennsylvania, it has 
been a better, more efficient process, and maybe that is, 
again, learning from lessons that started out in New Hampshire. 
Really, unfortunately, in New Hampshire is where we have 
experienced most of our issues.
    Mr. Lamb. Okay. Then as far as the provision of care 
itself, Chairwoman Brownley was asking a little bit about this, 
the increase in mental health provision in the community. Would 
you say that there is anything different about the way that you 
provide mental health or substance abuse treatment to your 
veteran patients than what they would get in the VA? I mean, I 
know, obviously, the setting is different, but as far as the 
actual care and the evidence it is based on and the style.
    Mr. Golnick. It is all the same evidence-based treatment. 
We actually partner quite well with the VA, with the local VAs. 
Our main focus is intensive outpatient treatment, which is the 
3 hours, 3 days per week of substance abuse treatment, and we 
also do outpatient. It depends on what the need of the local VA 
is. If they need us to do more outpatient treatment, we will do 
that as well.
    Mr. Lamb. I thought that is what you were going to say, and 
that makes me even more confused as to why it is difficult to 
reimburse on time, because it is not like you are providing 
something that the VA would not recognize. It sounds to me like 
the actual services, interventions, therapies, whatever you 
want to call them, toward your patients look similar to how 
they would be inside a VA hospital. Is that fair to say?
    Mr. Golnick. Yes, absolutely.
    Mr. Lamb. What do you think the friction point is as far as 
making sure that the bundle of services you provide once you 
get the authorization, what really is the friction point with 
the payer? Do they not understand what you are doing or----
    Mr. Frieman. Unfortunately, behavioral health is not really 
an understood side of the healthcare industry. For example, we 
are licensed as a facility, but some insurance companies 
accidentally consider us a provider group, which we are not. We 
are a facility. There are two claim forms. We submit via a 
facility claim form or a professional claim form, and so often, 
if a policy is not set to begin with, we will get the nod for 
using either or both. Really what it comes down to is, 
unfortunately, behavioral health is just progressing and 
becoming a healthcare industry that insurance companies are 
paying attention to.
    Mr. Golnick. I do want to emphasize that on the ground 
level, the actual clinicians that are setting the referrals up, 
they understand what we do, and we work very well together. I 
think once it gets past that level is where we start seeing the 
issues.
    Mr. Lamb. I see. Okay. The last thing I wanted to ask was 
do you have patients that take advantage of some of the types 
of services that VA is now offering under the whole health 
spectrum, so acupuncture, massage, nutrition, meditation, all 
that kind of stuff?
    Mr. Golnick. Absolutely. I think one of our main focus is 
to make sure that when the veteran comes to us for treatment, 
they understand and are aware of all those treatment options. 
Again, it goes back to the partnership with the VA. We are 
trying to make sure that these vets, a lot of them are hesitant 
to come to the VA, that they understand that there are all 
sorts of services that they are eligible for.
    Mr. Lamb. Do you tend to see veterans use some services at 
the VA and your services or is it more of a clean break from 
the VA institution once they come to you?
    Mr. Golnick. No. Back and forth. We mostly see back and 
forth.
    Mr. Lamb. Okay. I really want to thank you two for what you 
are doing. I know you do excellent work in my home State, as 
well as New Hampshire, and please keep it up. We will do 
everything we can to make it easier on you. Appreciate it.
    Mr. Golnick. Thank you, sir.
    Mr. Lamb. Mr. Chairman, I yield back.
    Mr. Pappas. Thank you very much.
    We are very lucky to having the ranking member of our full 
committee, Dr. Roe, here with us, and I will recognize him for 
5 minutes.
    Mr. Roe. Thank you, Mr. Chairman.
    If I had a problem getting paid with TriWest, the solution 
is right down at the end of the table right there. I would be 
speaking to him before I leave.
    Second, we have a guest in the room I just noticed sitting 
on the back row who did tremendous work on the Choice Program. 
I remember many nights I spent with Chairman Miller, Jeff 
Miller, who is in the back, who really teed all of the MISSION 
Act up with his work as chairman.
    Jeff, I want to thank you for all the work you have done 
for veterans. We would not really, I think, be having this 
hearing this afternoon had you not done the great work you did 
on the committee. I think Julia was here and Mr. Sablan. Thank 
you for that.
    Just a couple of questions. We have two generals here. I am 
going to salute the Army General. The question to you and Mr. 
McIntyre is, how long on average does it take for a new 
provider to become credentialed and begin seeing patients as a 
part of the network? Both of you can answer the question.
    Ms. Horoho. Thank you so much. Also thank you for your 
service as well.
    When we look at those to build the network first, I will 
kind of bring it in, and so one of the things that we started 
out doing is we looked at the civilian population, 2 percent of 
it, to build a very large network, and then now we have brought 
it down to using referrals, so we are very data driven.
    Once we identify providers that need to be in the network, 
we ensure that they are high-quality providers by credentialing 
them. The average time for credentialing is around 15 days. It 
can be a little bit longer because it is very dependent on 
providers submitting the information so we can do prime source 
verification, check their education, check the National 
Practitioner Data Bank. Then once that is done, then they are 
loaded into our system, and then they are available for the VA 
to be able to see to make a referral.
    Mr. McIntyre. We have a consistent process. It is overseen 
by Utilization Review Accreditation Commission (URAC). We draw 
from the nonprofit Blue Cross Blue Shield backbone for much of 
the network that we have access to. If you do a full 
credentialing process for a hospital, sometimes that can take a 
long time, and all of the associated practices that are tied 
with that, but most of the professional stuff fits into the 
same category of what General Horoho was talking about.
    Mr. Roe. One of the things that the whole idea of the 
MISSION Act was to say, Okay, the VA can not provide 
everything, the community can not provide everything for 
everybody, so we want to have a shared goal here, taking the 
best care of our veterans, and these networks are extremely 
important in doing that. I guess the next question I have is I 
am glad to see that Optum, which is our provider where I live, 
achieved a claims processing rate of under 12 days as of last 
month. Once Optum is paid, the network provider for care 
delivered to a veteran, how long does it take Optum to get paid 
from the VA?
    Ms. Horoho. Thank you for that question. Right now, we are 
actually getting paid in 5.8 days from the VA.
    Mr. Roe. The system, as I hear it, and we are here, and I 
know everybody up here has heard problems with it. I want to 
pass along to you all that overall--and that is what we are 
here, to work out those problems that we have heard here and 
other places. Overall, I agree with General Bergman; the 
satisfaction is up. I hear it where I travel. I travel all over 
the country, various VAs. I know my own VA at home, I have 
heard that very same thing at Mountain Home VA, so something we 
are doing is correct.
    Dr. Matthews, the next question for you is, does the VA 
assess veteran satisfaction and trust in the VA's community 
care programs specifically or just regard to VA healthcare in 
general?
    Dr. Matthews. We actually do both. It is a longer written 
survey by mail for community care trust only, so we are 
updating the more electronic surveys to get more real-time 
data, as we speak.
    Mr. Roe. What, if anything, do you think the rising VHA 
trust scores have to tell us about the rollout of the new 
community care program?
    Dr. Matthews. I would love to take full responsibility for 
that, but, no, it is obviously wholeheartedly in the fact that 
we are integrating the care that we provide. As you have 
recognized, the VA services cannot provide everything to all 
veterans alone. As we integrate, as we make it more efficient, 
as we make it more veteran friendly, veteran centric, their 
trust increases.
    Dr. MacDonald. If I may follow onto that, sir. You have 
given us the tools in the MISSION Act to truly make our system 
unified and veteran centric, and I think it is as we use those 
tools and Dr. Matthews' leadership in the modernization of 
community care that we are seeing that trust grow in both 
areas.
    I will just note that, in addition to our surveys, what we 
have been proud to see is that, for instance, in a Veterans of 
Foreign Wars of the United States (VFW) survey this year, 90 
percent of veterans said they would recommend VA to other 
veterans. That kind of external validation is what we are 
proudest to see, and we expect that to continue to grow as we 
continue to modernize.
    Mr. Roe. I think it has actually opened up more--the VA is 
actually seeing more patients within--inside the VA now that 
the MISSION Act has been--am I correct on that?
    Dr. MacDonald. Yes, sir. 2,100 more a day.
    Mr. Roe. Okay. Thank you.
    I yield back, Mr. Chairman.
    Mr. Pappas. Thank you very much, Dr. Roe.
    I will now recognize Mr. Bost for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman.
    Dr. Matthews, the eligibility criteria that the VA 
established was set specific drive times and wait times. Those 
criteria are different from the criteria that has been in the 
contract for Optum. This, you know, strikes me as it might be a 
problem on down the future. Can you explain why it was that you 
used rationale for doing that?
    Dr. Matthews. Sure, sir. Thank you so much for that 
question. The eligibility standards set under MISSION were the 
VA's promise about access, yes. However, in translating that to 
a contractual scenario in building a network, we do not want to 
build waste into a network. In building a network to a set of 
standards where we are not actually looking at the care or the 
services that we actually need to purchase, you are possibly 
contracting with providers, putting them through a 
credentialing process that is unnecessary because there is not 
necessarily care that we could refer to them. We will be 
building the standard based on veteran utilization, looking at 
the eligibility criteria, looking at how care is needed in each 
individual catchment area, and both of our partners have 
committed to that sort of really demand sizing. It is based on 
demand.
    Mr. Bost. Just to follow up, TriWest would be different 
than Optum, right?
    Dr. Matthews. Actually, every catchment area, every market 
is technically different----
    Mr. Bost. Okay.
    Dr. Matthews [continuing]. as there is different sets of 
services that may be needed.
    Mr. Bost. Okay. Same, Dr. Matthews, as well. One of the 
major new aspects of the MISSION Act was to allow for veterans 
to receive care from urgent care facilities. As part of this, 
veterans are expected to pay a copay, depending on the number 
of visits and what priority groups they are in. Does the VA 
know how many veterans have had to pay copays and which 
priority groups those veterans are assigned to?
    Dr. Matthews. Yes, we do. I apologize, I do not have that 
entire set of data memorized. I can definitely take that for 
the record and share that.
    Mr. Bost. That would be great. Thank you.
    General Horoho, I understand there has been a 10 percent 
increase in providers in Region 1 since December and that you 
expect that growth to increase. Is that the level of growth you 
expect to see in all areas implementation moving forward?
    Ms. Horoho. Thank you, sir, for that question. We are 
continually looking at the data, and as the referral data shows 
us where we may need to add different providers with different 
specialties, we are committed to do that. If you look at just 
in Region 1, you know, we have added over 20,000 more 
providers. We have added 44,000 care sites. We are not finished 
yet, because I really do believe, as this system continues to 
work well, we will have veterans using it, both the VA and the 
community care, and we will need to continue to respond and 
have an agile and robust network.
    Mr. Bost. What kind of growth have you seen in Region 2 or 
TriWest? Same, similar?
    Mr. McIntyre. On the TriWest side where we will be serving 
Region 4, we are taking an approach where we have sat down with 
each of the facilities to map out demand so that we can 
understand how to tailor the network, and we are constructing 
against what that will look like. Montana and eastern Colorado 
go live on April 7. We think because we have been at this for a 
while, that that approach should put us in pretty good stead, 
because our responsibility, as Chairwoman Brownley stated, was 
to make sure that we learned from the things that we have been 
through because we did precede Optum, and make sure that this 
is as stable as we can possibly make it. We are tailoring the 
networks to what we believe the demand is going to look like.
    Ms. Horoho. In Region 2, we have built over, you know, 120-
something thousand providers. We are continuing to build in 
that network as well, and we are using the same data-driven 
approach.
    Mr. Bost. Well, I want to thank you all for being here 
today. I know there is bugs to work out. There always is. I 
think we are headed in the right direction, and I look forward 
to the next hearings we have later on when the chairman sets 
those up.
    With that, I yield back.
    Ms. Horoho. Thank you, sir.
    Mr. Pappas. Thank you.
    I will now recognize Mr. Barr for 5 minutes.
    Mr. Barr. Thank you, Mr. Chairman, and thanks for holding 
this hearing.
    Obviously, the rollout of the MISSION Act has been widely 
watched by veterans across the country, certainly in my 
congressional district. Thank you to former Chairman Miller for 
your efforts in kind of laying the groundwork with the Choice 
Program. I do not think we would be here without--I would echo 
our current ranking member. We would not be here without those 
first steps.
    As the former chairman knows and as Dr. Roe knows, we did 
have problems with provider payments under the Choice Act. 
Confusion over the different authorizations and difficulties 
with referrals made the MISSION Act's passage a necessity.
    To all our panelists here today, thank you for the work 
that you do to serve our veterans.
    Let me start with an anecdote from one of my constituents. 
I represented a veteran who had difficulty using the Choice 
Program. He experienced significant delays in obtaining 
community appointments for cardiology and neurology. The 
finger-pointing that Mr. Golnick described is precisely the 
problem with the referral system that my constituent 
experienced.
    He was told by the VA that his case was referred to the 
TPA, but when he did not hear from anyone, he contacted the 
TPA, who then told him they did not have his medical records. 
When he called the VA back, there was some confusion, but 
ultimately we were able to help him and discover that the 
delays were due to a failure by his VA primary physicians to 
submit his consults to the third-party administrator. 
Meanwhile, precious time had passed, delaying care longer than 
if we think my constituent had just stuck with the VA and not 
even attempted to use the Choice Program.
    We hope that as we transition to MISSION, that that kind of 
a scenario would never happen to my constituent or any other 
veteran.
    I will start with Dr. Matthews. How confident are you that 
as we transition away from Choice and into the post-MISSION Act 
world, that that scenario that affected the veteran that I 
represent will never happen again?
    Dr. Matthews. If you do not mind, I will actually defer to 
my colleague. We actually do have an approach to this issue.
    Dr. MacDonald. Yes, sir. If you would be willing to share 
that veteran's information with us, I would like to make sure 
that that care has been delivered now and that that veteran has 
everything he or she needs.
    The approach we are taking to this, and as I mentioned 
earlier, we are delivering urgent referrals within 2 days. We 
are actually at 1.4, and that number continues to improve. That 
is better than the private sector, and we are proud of that. 
Where we have work to do is in routine referrals, and this has 
been traditionally a fragmented and antiquated process with the 
technology underlying it that has been also antiquated. What we 
are bringing ourselves to is in line with industry best 
practice, which is where we are standing up referral 
coordination teams, wholesale transforming our process.
    When a veteran leaves that primary care visit--you have two 
primary care clinicians here. When that veteran leaves the 
primary care visit or sees us via telehealth, immediately there 
is a team to engage that veteran and make sure they know the 
next step in their care, that that care is referred, processed, 
and that care is delivered.
    Our goal is to have all of these teams in place in every 
specialty by July of this year, and our goal is 3 business days 
or less for the processing.
    Mr. Barr. Great. Thank you. We will double check. I think 
that our veteran's issues were dealt with and he did get the 
care, but we will circle back to make sure, and I appreciate 
the offer.
    Dr. MacDonald. Thank you.
    Mr. Barr. General Horoho, as Region 2 in my district 
transitions from TriWest to Optum, ensuring an easy transition 
for the veterans I represent is a chief priority. As far as 
providers go, can you describe how you are deciding who to 
bring into the Optum network if the current UnitedHealth 
network does not meet access standards?
    Ms. Horoho. Thank you, sir, for that question. The first is 
to look at the 1.3 million providers that we have across 
United. We also then look at the data on capabilities that we 
may need to bring in. We get a preferred provider list from the 
VA on those preferred providers that either the Veteran Affairs 
Medical Center (VAMC) is used to using or veterans high-
referral rate. They give those to us. We then reach out to 
those providers. Then we have also had Members of Congress 
recommend different providers. We look at the big academic 
universities to bring those in as well.
    Mr. Barr. Yes. That is great, because I know the University 
of Kentucky Health System currently has a great relationship 
with the Lexington VA. They even share a medical bridge between 
the buildings. We hope that you would be looking at facilities 
like these to incorporate in the network.
    Ms. Horoho. Yes, sir. We are.
    Mr. Barr. Great. Very good. Also, are you working with 
TriWest to see what facilities have been seeing high volumes of 
veterans under their contract?
    Ms. Horoho. Yes, sir. We have weekly meetings with TriWest 
and with the VA and really look at the referral patterns, 
lessons learned. We are working very, very closely with our 
teams.
    Mr. Barr. Great. Thanks so much. Again, I think we are 
making a lot of progress with the MISSION Act. I appreciate all 
of your participation and implementation. Thank you.
    I yield back.
    Ms. Horoho. Thank you, sir.
    Mr. Pappas. Thank you.
    We will attempt to do a second round of questioning here. 
We are going to bump up against some votes at a point in time, 
but we appreciate your patience and hopefully answer a few more 
questions here before we have to head upstairs to vote.
    One question I have. I just wanted to follow up, Mr. 
McIntyre, on the issue of outstanding claims. You mentioned 
that late last year, systems were jammed up. There was a 
backlog of several hundred thousand claims. You have been 
working through that. Can you just tell me where that stands, 
especially as it refers to Region 1? As I hear from providers 
that say they have legacy claims with TriWest, what we should 
do to work through those.
    Mr. McIntyre. You bet. Thank you for the question, Mr. 
Chairman. Earlier in the hearing, Dr. Matthews talked about the 
fact that the fee schedule update that we get every year was 
very late in coming out. The VA has made changes to make sure 
that that does not happen again, which is a good thing, and she 
is to be commended for that. We ended up with 400,000 claims 
getting backed up, because they have to be stopped while the 
payment updates go into place. As Dr. Matthews said, the file 
was not even in very good shape when it came across, so it took 
longer still to get it taken care of.
    The day after Thanksgiving, which is when the VA and I 
started working on this, along with our teams, there were 
400,000 claims in a queue that were stopped. We did a 
prognostication and found that it would probably be the middle 
of the year before we would be done, and we decided that that 
was unacceptable between us, and we will finish the burning 
down of that 400,000 by next week.
    We put all the chiropractors, the home health providers, 
others for which the margins are very narrow, we put them in 
the front of the list, and those are on the way out the door. 
Then we are filing the invoices with VA to get reimbursed for 
the money that we will have paid out of our own pocket.
    Mr. Pappas. Okay. I want to ask a question for the VA about 
alternative treatments. I have met with 10 constituents 
recently in my district that talked about their experiences 
with acupuncture to treat chronic pain and Post Traumatic 
Stress Disorder (PTSD), and to a person had all surprised 
themselves with how this was improving their quality of life, 
their day to day. It was allowing them to lead a full life 
without having to take pain medication, so potentially some 
savings for us within the system too.
    I am wondering about some information that we received on 
caps on the number of authorized visits for certain services, 
including acupuncture. Do you have any more information about 
that? We had requested that a while ago. If you do not have it 
now, can we follow up and get the detail on that? I am 
concerned about there being new caps in place that will reduce 
the number of visits that these individuals can receive.
    Dr. Matthews. It is a great question and one I can 
definitely clarify as well as assure that our teams get you the 
answer in writing. There is a differentiation that we make 
between--within alternative care. You could have acupuncture or 
even yoga or massage therapy for the actual treatment of a 
condition, so it is actually prescribed to take care of pain or 
some other modality, versus our whole health and wellness 
packages. Acupuncture, yoga could actually fall into both.
    Currently, as I was describing earlier, the standardized 
episode of care do have limitations on number of visits. 
However, if for treatment purposes as opposed to whole health 
you need additional authorization, the requesting provider can 
get in touch with VA and we will authorize more care. There is 
not a maximum, there is not a final when it is for treatment of 
conditions.
    For whole health, we do have limitations per year, and that 
is really just in order to curtail and not necessarily have 
overutilization, but it is a quite high rate. For instance, for 
yoga, we approve 30 classes a year. That is more than one a 
month. That is two a month for wholeness, again, not for 
treatment of actual conditions. That is really just to make 
sure that we can circumscribe usage of services. For treatment, 
again, with an additional referral request, that veteran can 
continue the services.
    Mr. Pappas. Okay. I think we might need to get some 
additional information out to providers to help clarify that 
issue, so maybe we can work with you on that.
    Dr. Matthews. Definitely.
    Mr. Pappas. I will recognize Dr. Dunn for 5 minutes if he 
has questions.
    Mr. Dunn. Thank you, Mr. Chairman. I am glad we have a 
second bite at the apple.
    I am not sure who is the best person to answer this 
question, but if a veteran needs or wants, needs or wants, you 
know, a certain provider who is not a member of the provider 
network in their area, what happens? Is that honored or is 
there a way to get there, or no?
    Ms. Horoho. I will go ahead and start with that, and then 
anybody else can chime in.
    We are in regular dialog, and so if there are veterans that 
have a preference of a provider and they are not in our 
network, we do assess if they meet the quality standards and 
work very hard to get that veteran in.
    We have also made a commitment, the three of us, that if 
there is a veteran that is already receiving treatment and we 
are getting ready to change from one TPA to another, that that 
veteran gets to continue with that episode of care.
    Mr. Dunn. While we have got the general here in line, can 
you clarify once and for all on the record, is it possible to 
be a provider to the VA in Optum and not United?
    Ms. Horoho. Yes. Absolutely.
    Mr. Dunn. Okay. You can be United and VA?
    Ms. Horoho. Our network draws upon----
    Mr. Dunn. I just wanted you to say it publicly.
    Ms. Horoho. Publicly, we welcome anybody that meets the 
high-quality standards to be able to serve our veterans. 
Absolutely.
    Mr. Dunn. Thank you.
    Dr. Matthews, there was some talk about a national nurse 
line. Is that going to happen?
    Dr. Matthews. We have actually some longstanding plans to 
develop what we call clinical contact centers. It is not in our 
immediate future just because that is a pretty large, expansive 
project. Jen, I do not know----
    Mr. Dunn. Enough nurses for a whole country?
    Dr. MacDonald. Yes. Thank you. Actually, in the VA Sunshine 
Network, this has launched, so we do have tele-urgent care. 
What that means is when a veteran contacts us in that contact 
center--and we are working to bring this across the country, 
which will take us a bit of time. What that means is when a 
veteran contacts us, we can actually spin up a video visit with 
a single link to that person's mobile device in their home, in 
their living room, and get that care met without them even 
having to move. That is what we are aiming to bring across the 
country, and so yes. Modeling after Defense Health Agency 
(DHA), which has an excellent nurse call line, we are aiming to 
bring these into regional areas and bring in the telehealth 
capability.
    Mr. Dunn. Thank you very much.
    Mr. Chairman, I yield back.
    Mr. Pappas. Chairwoman Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    Dr. Matthews, I wanted to go back to our trip to the 
Dakotas, and I think we both learned a lot on that trip and 
hearing from Tribal leaders and trying to better understand the 
unique needs and experience of our Native veterans. Certainly 
we heard a lot of challenges around coordination of care 
between the VA and Indian Health Services and the community.
    I was just wondering, based on that visit, is there 
anything that you are planning on working on to help improve 
that coordination of community care for these veterans?
    Dr. Matthews. Thank you, Chairwoman. Glad you asked. 
Actually, yes. I am actually putting together a proposal to our 
executive in charge about some different steps. I will 
definitely share those details with you. I will also be meeting 
with the Office of Rural Health about the Memorandum of 
Understanding (MOU), giving them some feedback from our trip, 
trying to put a lot more teeth into the effort, as well as take 
into account local MOUs and bridging those communication 
divides that we even saw that were bridged while we were 
together in South Dakota. Yes, taking a lot of steps. I do not 
want to get too ahead of my leadership before I can share them 
publicly, but I can definitely share as we move forward.
    Just of note, I actually do have a listening session with 
Indian Health Service (IHS) and Tribes tomorrow at the Capitol 
Hilton. I am also scheduled for a travel consultation in San 
Francisco later next month. I am very excited about the 
progress.
    Ms. Brownley. Very good. Thank you. Thank you very much. I 
will look forward to hearing about what you are doing, and 
hopefully you will keep me abreast of that as well.
    Mr. McIntyre, I will go back to asking you the question 
that I did not have enough time for before. Just again, you 
know, with a big increase of mental health services within the 
community, you know, I just want to make sure that those 
veterans are getting, you know, those wraparound services; 
things like, you know, homelessness, issues around, you know, 
housing for veterans, issues around education for veterans, 
issues around job opportunities for veterans. I am concerned 
that maybe the physician in the community is not going to be 
aware of some of those programs, and just wondering if you are 
making that connection.
    Mr. McIntyre. When the referral comes to us, it comes from 
VA, and so our expectation would be that the VA is looking at 
what are the needs of that individual as that referral comes 
our direction. Also, what State are those veterans in, right. 
Are they red on the threat scale or are they green on the 
threat scale, right, so that we can make sure that things are 
properly triaged.
    My feeling in this space is that we are probably all a 
little bit ahead of ourselves in terms of how the demand has 
gone up for care that needs to move into the community in order 
to be able to meet the standards that are required under 
MISSION. We on our end as a company have stepped back at a 
senior leadership level to say do we want to change the model 
even for how we are doing the appointing support in the mental 
health space, and we are assessing that at the moment.
    We are going to sit down with the VA in our communities and 
say does the model that we are thinking about going to put us 
in a better space, because you have really got to have a 
circular loop that you can tie people back into both within the 
VA itself but when people move into the community. We will 
leverage, likely, some of the work that we do supporting the 
Defense Department services, Marine Corps, and others in the 
space of threat and tie people together with the VA through 
that lens.
    Ms. Brownley. Very good. Just to General Horoho and Mr. 
McIntyre, just in terms of training for mental health, how is 
that deployed?
    Ms. Horoho. Thank you, Chairwoman Brownley. We have got--we 
use PsychArmor as one of our training modules that are online, 
very robust of understanding the culture of the veteran, 
behavioral health, sexual assault, military related sexual 
assault. Those training modules are all online at the portal 
where our physicians can access that. We also draw upon--we 
have over 66,000 behavior health providers that we are tapping 
into in our network so that we are very robust there.
    Then the other area that I think when you talked about 
behavioral health, there is a close relationship between 
substance abuse, and so we have Medication Assisted Treatment 
(MAT) centers, 30 minutes drive with all of our veterans in the 
area. Trying to link all those together.
    Ms. Brownley. Thank you very much.
    Mr. McIntyre. A similar strategy on our end.
    Ms. Brownley. I have to yield back because I am running out 
of time.
    Mr. Pappas. Thank you.
    I will recognize Mr. Bergman for 5 minutes.
    Mr. Bergman. It is not going to take 5 minutes.
    Mr. Dombi, would you tell me how long on the average it is 
taking to get the credentials for your providers?
    Mr. Dombi. Providers are reporting to us that it has been 
taking several months. It is not just credentialing. You start 
with a contracting approach, then you get into credentialing. 
Then you get loaded, not in the New Year's Eve sense, but you 
get put into the system. The word ``loaded'' came from Optum, 
so it is taking months to get there.
    Mr. Bergman. Okay. You know, General Horoho and Mr. 
McIntyre, does your organization have timeliness goals for 
credentialing a provider? If so, what is it? Do you have 
numbers on the actual rate, because we are trying to match up. 
Are we doing too much of reinventing the wheel when it comes to 
credentialing? I mean, what has changed? What is the same? What 
can we carry over? How can we match up but not waste time?
    Ms. Horoho. I will go. I will start.
    I will use the example of home health, if I could. When we 
look at home health, which is extremely important, and there is 
actually extended care. We have already contracted and loaded 
and have available over 6,100 providers to provide care in that 
area. When we talk about--and Bill and I had this conversation 
outside. There are providers that are still in the system 
waiting to be loaded into our system and then available. The 
majority of those are all in Region 3 where we have not gone 
live, and we will not go live for several months. They will be 
in the system. One of them, Amedisys, which we have contracted, 
they will be fully available at the end of March. We are not 
even going to be live in Region 3 by the end of March.
    Some of that long system is more of, as we roll this out in 
a phased manner, we made sure that we had those that we needed 
to be available for the areas that we were implementing at that 
time.
    Mr. Dombi. To Optum's credit, you know, once we got into 
conversation, you know, resources were committed to bringing 
these home health agencies and other home care providers in 
there. I mean, there are thousands of providers out there for 
services, but we have absolutely seen improvement in the 
process that has been employed by Optum in that regard.
    You know, we kind of set a goal, or at least I did, that we 
would not hear from any veteran at Christmastime that they 
could not get access to care. Hopefully, they all did get the 
access to care because Optum did step up and started bringing 
things forward. Maybe this was a shakedown cruise.
    Mr. Bergman. Mr. McIntyre, go ahead, if you had comments. 
Thank you.
    Mr. McIntyre. We will be credentialing the network for 
Region 4 as we go into each one of those areas. We currently 
have the 700,000-some providers that we are using in a variety 
of different forms of credentialing, depending on how they show 
up in the network.
    Dr. Dunn and I had a conversation about this yesterday 
about one particular practice, sir, in your area. There was a 
visit paid there today. They thought that they had provided us 
all the files. The files are coming tonight, and we will have 
that done within the next 5 days.
    Mr. Bergman. Well, again, thank you, on behalf of Dr. Dunn. 
We speak for each other from time to time. We never have to 
think about what we are going to say because we kind of got the 
Vulcan mind meld going here. You guys have been around a long 
time.
    You know, I guess I will just conclude by saying thanks for 
what you are already doing. It is always a good idea to try to 
put yourself in that other entity's shoes, back and forth, to 
see if you really would like it to be done to you like you are 
doing to others. I think that is maybe the golden rule. We can 
go, I believe, a long way to making sure we are sending a 
signal that we are moving forward as partners with the VA and 
with all of you providing those services. Thank you.
    With that, I yield back.
    Mr. Pappas. Thank you, General Bergman.
    Would any of the members like to offer any closing 
comments?
    Well, seeing none, I want to thank all our witnesses for 
joining us today. I think it is clear that the only way that 
veterans can receive timely care in the community is through a 
very collaborative process among all the players involved, 
community providers, the VA itself, and the contractors who are 
hired by the VA.
    Community providers have much to offer our veterans but 
only if they can navigate the complexities of VA's referral 
authorization and payment processes. I think we heard today 
that these are a work in progress and more needs to be done.
    I want to thank everyone for joining us here today, 
particularly our community providers, Mr. Dombi, Mr. Golnick, 
Mr. Frieman, for joining us here. Your voice is so valuable as 
part of this process. Thank you to the VA contractors and the 
VA as well for your testimony here today. I think we all have a 
commitment to working together to make sure that we address 
some of the issues that were raised in a way that can open 
doors for our veterans to receive the best care possible.
    With that, members will have 5 legislative days to revise 
and extend their remarks and include any extraneous material.
    Without objection, the subcommittee stands adjourned.
    [Whereupon, at 3:46 p.m., the subcommittees adjourned.]   
      
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                         A  P  P  E  N  D  I  X

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                     Prepared Statement of Witness

                              ----------                              


                 Prepared Statement of Kameron Matthews

    Good morning, Chairwoman Brownley, Chairman Pappas, Ranking Member 
Bergman, Ranking Member Dunn and Members of the Subcommittee. I 
appreciate the opportunity to discuss Provider Relations During the 
Transition to VA's new Community Care Program. VA has continued to work 
with our providers to ensure Veterans receive the best care possible. 
Community providers are integral to VA's ability to provide Veterans 
with greater choice of and access to timely, high-quality heath care. 
VA is continuously striving to enhance relationships with community 
providers by improving technology systems, deploying new tools to 
enhance efficiency with electronic file sharing and to address payment 
timeliness.

Introduction

    This is a time of transformative change at VA. MISSION Act 
implementation is succeeding and has become part of our core business. 
We are now in a phase of proactive refinement and enhancement. We have 
moved beyond planning for individual sections and are strategically 
knitting together the tools you've given us into a future vision for 
the organization. As we have demonstrated this year, we will lead the 
U.S. healthcare industry forward. You will see us focus and lead on 
modernizing our operations, bringing us in line with industry standards 
in key areas like claims processing and referrals. Alongside our 
Department of Defense and Department of Health and Human Services 
partners, we intend to lead the industry in quality, health information 
exchange, opioid safety, and ultimately care coordination powered by a 
joint electronic health record.
    And importantly, you will see us lead in meeting Veterans where 
they are, including in rural areas. We have launched an effort to 
synergize and augment the range of solutions available to Veterans in 
these areas, including mobile care teams, telehealth, and the expanded 
reach of our new community care program. We are building a cohesive 
strategy that will deliver care for Veterans no matter where they 
choose to live or seek the care they need.
    As your staff have seen, we now leverage VA's first-ever Joint 
Operations Center to operationalize this type of enterprise strategy--
viewing enterprise data and monitoring risks and opportunities across 
the Nation. Business intelligence is driving decisions like never 
before and, as we have demonstrated this year, business intelligence is 
centered on an excellent experience of care for Veterans, their 
families, and the important people in their lives.

Community Care

    On June 6, 2019, we successfully launched the new Veterans 
Community Care Program, a cornerstone of the MISSION Act. Expanded 
eligibility criteria, improvements to processes and technologies, and a 
growing network of community providers are just some of the ways that 
the MISSION Act has improved the options that Veterans have to address 
their health care needs. Since the launch, VA has placed more than 3.6 
million referrals and authorized more than 3.85 million episodes of 
care. In these early referral patterns, it appears Veterans have 
improved access to specialty care. Eligibility criteria ensure that the 
clinical needs of the Veteran are accounted for and, when appropriate, 
that a Veteran can work closely with his or her provider to choose the 
best setting and clinician in his or her best medical interest.

    Since implementation, VA has been developing and deploying 
improvements to the new Veterans Community Care Program that improve 
the experience of Veterans, community providers, and VA staff. VA is 
modernizing its information technology (IT) systems to replace a 
patchwork of old technology and manual processes that slowed down the 
administration and delivery of community care. Once fully implemented, 
the new IT systems will speed up all aspects of community care--
eligibility, authorizations, appointments, care coordination, claims, 
payments--while improving overall communication between Veterans, 
community providers, and VA employees.
    We intend to continue this trajectory and make ourselves the most 
accessible and convenient health care system in history. You have given 
us the tools to do so. The new streamlined community care program is 
easier for Veterans and their families to navigate, and our network of 
more than 880,000 providers, which complements care delivered through 
VA facilities and by telehealth, provides an unprecedented range of 
options. VA remains committed to strengthening the VA health care 
system, expanding access, and pushing the boundaries of what is 
possible in serving our Nation's Veterans.

Urgent Care Benefit

    VA has also implemented a robust contracted network of urgent care 
providers that is a great new benefit for enrolled Veterans who need 
immediate care for minor injuries and illnesses. As of January 2020, 
more than 6,400 urgent care centers have joined VA's urgent care 
network, which is currently managed by TriWest. About 90 percent of the 
country's Veterans eligible for the urgent care benefit are now covered 
by a network urgent care provider, and since June 2019, they have 
provided care to Veterans in more than 160,000 visits.

Conclusion

    In conclusion, we knew when we began implementing the MISSION Act 
of 2018 that we had the potential to make an enormous positive impact 
for Veterans. More than six months later, we know that is the case - 
with the new tools you have provided us, VA is helping more Veterans 
access the care and services they need. We will continue to work to 
improve Veterans' access to timely, high-quality care in VA facilities 
and by virtual means, augmenting this with excellent choices through 
our robust network of community partners.
    I am proud of the future we are building on behalf of Veterans and 
their families, and this Committee's continued support is essential to 
ensure it is realized. Mr. Chairman, this concludes my statement. I are 
prepared to answer any questions you may have.
                                 ______
                                 

                Prepared Statement of David J. McIntyre

Introduction

    Chairwoman Brownley and Chairman Pappas, Ranking Members Dunn and 
Bergman and Distinguished Members of the Health and Oversight and 
Investigations Subcommittees, it is a privilege to appear before you 
today. Thank you for your principled leadership and unwavering 
commitment to ensuring the Department of Veterans Affairs (VA) provides 
America's Veterans with timely access to the high-quality care they 
deserve, both within VA health care facilities and in the community.
    Since 2013, those of us associated with TriWest Healthcare 
Alliance, from our company's non-profit and university health system 
owners to our nearly 3,500 employees, have proudly served as a 
committed partner to VA, working every day to ensure VA has a robust 
network of proven and effective community care providers to meet the 
unique health care needs of our Nation's Veterans.
    In fact, many of our employees are Veterans or Veteran family 
members committed to serving their fellow Veterans. TriWest has a long 
history of hiring those who have served this great nation in uniform; 
we understand that shared military experiences foster trust with fellow 
Veterans. For us, there is no higher calling than supporting government 
in giving back to the brave men and women whose selfless sacrifices 
have made this the greatest nation on Earth.
    For example, at our Operations Center in El Paso, Texas, where 
support is provided for Veterans by processing health care requests, 
handling inbound and outbound telephone calls with Veterans and health 
care providers, and scheduling appointments for Veterans in the 
community with providers in El Paso and across Texas, we have hired 
many Veterans and Veteran family members to fill these important 
positions.
    I would like to take a moment and highlight an extraordinary Army 
Veteran and El Paso native who was one of our first employees at the 
Operations Center. This great Veteran served our country through 
multiple deployments and is also the mother of an Air Force Veteran. In 
the Army, she oversaw the medical readiness of 1,200 soldiers. She now 
uses her leadership, organizational and team building skills to mentor 
Veterans transitioning into the workplace and to serve her fellow 
Veterans through our community care efforts. In the wake of last year's 
senseless and tragic shooting in El Paso that killed 22 people and 
injured 24 others, including two cherished TriWest employees, we are so 
grateful to have dedicated leaders like this Veteran as we embark on 
our renewed mission of supporting VA under the MISSION Act.
    We are proud to have earned the opportunity to continue providing 
that vital support of VA in 2020 and beyond under the Community Care 
Network (CCN) contract for Region 4. We appreciate the opportunity to 
provide a detailed update on our progress of partnering with VA to 
implement CCN in Region 4, as well as our ongoing efforts to meet the 
current needs of Veterans through our existing Patient-Centered 
Community Care (PC3) contract and our support of the transition of VA 
facilities to VA's new partner - Optum Public Sector Solutions, Inc. - 
for CCN Regions 1, 2 and 3. While we find ourselves at yet another 
point of transition this year - to the new CCN regions - a transition 
that will take some time to get right, much is moving in the right 
direction and the system of care that will ultimately exist for all 
Veterans under the MISSION Act is starting to emerge as we gather here 
today.
    One example of the partnership and effective ``team based'' effort 
needed to serve the needs of our Nation's Veterans was conveyed to me 
by an Army Veteran from the Phoenix area. Like so many, he epitomizes 
the greatness of our country and the men and women who wear the 
uniform. He is a two-time cancer survivor and credits his recovery to 
the joint care he received from the Department of Veterans Affairs and 
in the community. VA health care providers and community care providers 
are partnering and collaborating together to save lives. This Phoenix 
Veteran now generously gives of his time and volunteers at a local VA 
clinic to help serve his fellow brothers and sisters. The dedicated 
Veteran-centric partnership, between VA and community health care 
professionals, is the heart and soul of the work in which we are all 
engaged under the VA MISSION Act.
    Thank you for your bipartisan determination to focus us all on the 
right objectives to help VA honor its sacred mission and transform its 
services to improve care for Veterans today, tomorrow and well into the 
future. It is work worthy of nothing but our very best, and we consider 
ourselves very fortunate to be a part of the dedicated team all working 
together in support of our Nation's heroes!
    America's Veterans have earned the very best care possible and that 
includes a robust VA system of care as well as community care options 
when necessary. Our role at TriWest is to strengthen and support the 
overall VA system of care and ensure that Veterans are always at the 
center of everything we do. It is a solemn responsibility that we take 
very seriously.

History of Service to Veterans and Service Members

    To better understand where we are going and how we can continue to 
improve VA community care services for Veterans, we must understand 
where we have been, what has worked and what must be improved. I would 
like to share with you some background on TriWest's history of service 
to America's military and Veteran communities, and some lessons learned 
along the way.
    TriWest Healthcare Alliance has been privileged to be engaged in 
the important work of providing Veterans and military beneficiaries 
with community care services since being awarded its first contract on 
June 27, 1996. Our first 18 years were spent helping the Department of 
Defense stand-up, operate and mature the now very successful TRICARE 
program. Some would say that experience prepared us to effectively 
serve alongside VA as a full partner during a time of great challenge. 
In our book, there is no greater privilege than to be doing our part as 
grateful citizens to serve those who have so honorably served in 
defense of our Nation at home and abroad.

Supporting VA Since 2013

    In September 2013, VA selected TriWest as the Patient-Centered 
Community Care (PC3) Third-Party Administrator (TPA) to support VA 
community care needs in three PC3 regions encompassing all or parts of 
28 states and the Pacific. Several months later, the Veterans Access, 
Choice and Accountability Act (VACAA), which included the Veterans 
Choice Program, was enacted in response to a wait list crisis that 
first was discovered in our hometown of Phoenix, Arizona in April 2014. 
Congress gave VA 90 days to stand up the program, and VA asked TriWest 
to assist them in doing so. We worked diligently with VA to implement 
the Choice Program, and then with VA and Congress to refine it.
    During the five-years the PC3 and Choice programs were operational, 
VA, Congress and TriWest worked to refine these community care options. 
Ultimately, more than 90 program improvements and contract 
modifications were made - both to enhance the PC3 and Choice programs 
to better serve the needs of Veterans and to arm VA with additional 
tools to support its eligible Veteran population. These improvements 
ranged from the addition of primary care services to PC3, to expanding 
the mental health and women's health provider bases, and to conducting 
collaborative and comprehensive demand capacity assessments at the 
local VAMC level to determine optimal community care provider sizing 
and configuration.
    In the fall of 2018, VA extended TriWest's initial PC3 contract and 
asked us if we would agree to expand our services in all 50 states, 
Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the 
Northern Mariana Islands until the next generation of VA community care 
- the Community Care Network (CCN) - could be fully implemented this 
year. We agreed to do so. We began expansion efforts on December 7, 
2018, and completed the expansion in spring 2019. Upon completion, we 
provided VA with access to a nationwide network of community providers 
to serve Veterans in all 50 states and territories. In addition to 
providing VA with a consolidated network of community providers and 
processing and paying their claims, TriWest also is performing 
appointment scheduling and providing customer service support in 
several areas as the CCN contracts are implemented. It has been an 
honor to serve constituents from all of your districts and states and 
to help stabilize the enterprise across all states as we all awaited 
the conversion to CCN in Regions 1, 2 and 3.

Progress Improving VA Community Care Services

    From the beginning of our work in support of VA in 2013, TriWest 
has worked diligently to focus first on understanding and then 
responding to VA's specific needs at all levels - the local VA Medical 
Center (VAMC), the Veterans Integrated Service Network (VISN) and VA 
Central Office (VACO). Today, TriWest's provider network - tailored 
through use of VA demand and capacity assessments - is comprised of 
over 690,000 individual providers who represent more than 1.3 million 
access points. This robust network has helped to ensure that minimal 
authorizations for care had to be returned for no provider being 
available - currently less than 2 percent, in fact. TriWest's tailored 
network has delivered more than 24 million total appointments since the 
start of this privileged work supporting VA community care.
    At its apex, with TriWest serving nationwide, we received more than 
400,000 requests for Veteran care in the community per month, are 
handling approximately 700,000 calls per month, and to date, we have 
processed and paid over 25 million health care claims to community care 
providers. Up until a complication with the annual fee update file 
arriving late, which backed up 400,000 claims... and is close to being 
fully resolved, we had been processing and paying clean claims, on 
average, within 18 days in our legacy area, and within just 10 days in 
the expansion states - with an accuracy rate of 96 percent. And, as you 
know, we still function without access to a Federal bank account from 
which to draw, so we are paying the claims on the front end and then VA 
is reimbursing us on the back end. That is working much better than it 
was when we had more than $200 million in outstanding payments owed our 
company; however, a few pieces still lack resolution due to the 
enormity of VA's list of critical issues to work. We remain hopeful 
that these pieces still will be resolved, and are partnering together 
to make things work for Veterans and the providers leaning forward in 
support of VA.
    As TriWest transitions out of CCN Regions 1-3 and ultimately 
reduces its footprint to CCN Region 4, the volumes of work will re-set 
accordingly, and we will singularly focus on supporting the enterprise 
and its service to Veterans in that area of the country.

VA Stakeholder Collaboration--Listening & Learning

    As we shared with the Health Subcommittee last September, TriWest 
has proactively engaged with Veteran Service Organizations and other 
key stakeholders since 2013 to gain a better understanding of how we 
are doing and where improvements need to occur. Examples of this 
engagement over the past year include:

      Attendance at over 50 VA Town Halls, with active 
involvement/outreach to Veterans in attendance.

      Participation in more than 35 congressional Town Halls/
Veteran Resource Fairs/Briefings.

      Distribution of monthly congressional updates to all 
congressional (DC) offices across the country with statistical data and 
general program updates (January 2019 - January 2020).

      Conducting 7 teleconference briefings on expansion 
efforts with congressional staff - district/State and DC staff - across 
11 VISNs, attended by approximately 350-400 staffers.

      Conducting 7 teleconference briefings on expansion 
efforts with local and State Veteran Service Organizations, County 
Veteran Service Officers and Veteran non-profit representatives across 
11 VISNs, attended by approximately 300-350 Veteran representatives.

      Participation in Veteran Stand Downs designed to ensure 
homeless and low-income Veterans are aware of, and educated on, 
community care benefits.

      Supporting and attending 10 national VSO conventions and 
VA events between January and December 2019, connecting with thousands 
of Veterans and providing education and issue support. Events included:

          o Paralyzed Veterans Wheelchair Games

          o VFW, DAV, American Legion and VVA national conventions

          o National Association of State Directors of Veterans Affairs 
        national convention

          o National Veterans Summer Sports Clinic

          o National Disabled Veterans Winter Sports Clinic

    Since the beginning of our work on behalf of VA, we also have 
focused on provider education, seeking to minimize provider confusion 
and Veterans challenges with community care. In 2019, TriWest:

      Conducted 526 provider education webinars with a total of 
3,911 attendees (April 2019 - December 2019).

      Issued 16 fax blasts to more than 850,000 recipients with 
topics relating to provider education or provider relations (January 
2019 - December 2019).

      Issued 12 monthly Provider Pulse e-newsletters to an 
average of 50,222 recipients, resulting in an average open rate of 26 
percent (January 2019 - December 2019).

    We will continue these proactive communications and education 
efforts as we transition to CCN.

MISSION Act Launch

    Thanks in large part to the principled and diligent work of the 
House and Senate Veterans Affairs Committees in crafting the VA MISSION 
Act in 2018, VA has been armed with the authorities to reset the 
enterprise and, among other things, move the community care benefit to 
one that is more streamlined. Shortly after expanding our services 
across the country, VA and TriWest turned to collaborating in the 
implementation of the first community care components of the VA MISSION 
Act. TriWest and VA program leadership and project management teams met 
face-to-face on numerous occasions to discuss previous lessons learned 
and collaborate on the processes needed for a successful implementation 
and management of the MISSION Act requirements.
    Thanks to the extensive collaboration on VA MISSION Act 
implementation, this much-needed reform of consolidating VA's various 
community care programs into a single community care program is now 
underway and beginning to make a positive difference for Veterans. The 
consolidation is helping to eliminate redundancies, reduce provider 
confusion, synchronize standards and rules, streamline processes and 
innovate vital community care services. Since the launch of the MISSION 
Act on June 6, 2019, over 2.7 million initial appointments have been 
scheduled with the providers in our community care network.

Urgent Care Benefit

    As you well know, one of the most significant new benefits for 
Veterans contained in the MISSION Act is the addition of an urgent 
care/retail clinic benefit. Under the law, eligible Veterans can now 
visit an urgent care provider in VA's network for non-emergency yet 
time-sensitive, pressing health care services if they have received 
care through VA or a community provider within the past 24 months.
    Since the MISSION Act went into effect on June 6, 2019, TriWest has 
developed a national network of urgent care providers. We also added 
pharmacy services for urgent medication requirements, created an online 
urgent care provider locator tool, developed a series of tools and 
education materials for urgent care providers, and partnered with VA to 
perform outreach to Veterans to spread awareness of the new benefit. In 
addition, we proactively sent information packets complete with signage 
and Frequently Asked Questions (FAQs) to each urgent care facility upon 
contracting to be in the network. While we continue to work to ensure 
that Veterans across the country have ready access to urgent care when 
needed - within 30 minutes of their home - our urgent care network is 
delivering access to timely care.

    Key statistics that demonstrate this fact as of January 2020 
include:

      Over 6,500 urgent care and retail locations are currently 
in our network.

      There have now been more than 175,000 urgent care visits.

      There have been more than 15,000 calls to the Urgent Care 
support line, which exists to assist Veterans, Urgent Care Centers and 
Pharmacies that are struggling with the use of the benefit... providing 
education and technical support at the point of encounter. This was 
deemed critical by TriWest and VA with a brand-new benefit, especially 
given this population presents differently than any other... given that 
there is no insurance ``card.''

      The ``2019 VFW Our Care'' report, VFW's most recent 
survey on the State of VA health care, notes that ``an overwhelming 
majority of veterans, 89 percent, indicated that they would recommend 
community urgent care to other veterans.''

    Currently, 90 percent of eligible Veterans have access to at least 
one urgent care provider within 30 minutes of drive time, access that 
appropriately and substantially exceeds even Medicare standards (70 
percent). That said, we are continuing to add providers until we reach 
our personal goal of all Veterans having access to an urgent care 
facility within 30 minutes, if a facility exists in their area and is 
willing to be available to meet the needs of those heroes who call 
their community home. For our part, we will continue to stay focused on 
working at VA's side in refining processes to ensure that they are 
simple to execute and that provider bills are processed and paid 
quickly and accurately.

CCN Region 4 Implementation

    On August 6, 2019, VA awarded TriWest a CCN contract to administer 
VA's 13-State Region 4 territory. Under the CCN contract, TriWest is 
responsible for building and maintaining a network of community health 
care providers, paying claims and providing customer service.
    TriWest and VA conducted a CCN Region 4 kickoff meeting in Denver, 
CO, in early November 2019. At that meeting, TriWest briefed VA on our 
CCN Region 4 approach for implementation that included a detailed list 
of contract interdependencies and clarification questions. Subsequent 
to the kickoff meeting, TriWest and VA have established several joint 
work groups covering key functional areas such as training, claims and 
invoicing, network adequacy, customer service, clinical quality and 
systems integration and testing. These work groups are designed to 
refine new and existing processes, achieve informed decisions and 
implement lasting solutions.
    Under CCN, there are several VA community care process changes, as 
well as the inclusion of several services and benefits that were not a 
part of PC3 or Choice. These changes require us to re-engineer existing 
solutions and systems, implement new services and review and test 
revised processes with VA. The work groups allow VA and TriWest to work 
on these changes collaboratively, ensuring consistent approaches and 
understanding.
    In addition to conducting focused work group sessions and working 
to re-architect our systems and processes to make them CCN-ready, 
TriWest and VA also have worked closely with the leadership of each 
VISN and VAMC to assess Veterans' community care needs in their 
respective markets to ensure that we will have a network optimally 
tailored to support them. Through our years of working in collaboration 
with VA, we know it is essential to customize the network of community 
care providers according to the unique demand and referral patterns of 
each VA facility. That approach enables the network to effectively 
supplement VA's internal capacity, providing VA, and ultimately 
Veterans, access to the right care at the right time from the right 
provider.
    To develop a customized network sized for VA in each market and 
tailored to its specific needs, TriWest initiated a process with VA to 
assess demand and determine the distribution and supply of network that 
would be needed in the community to support that demand. We call it the 
``Demand Capacity Assessment Process.'' We first leveraged this 
approach with VA in 2014, for a process over Memorial Day weekend in 
preparation for assisting the Phoenix VAMC in driving down the backlog 
of nearly 15,000 Veterans waiting in line for care. This tool allowed 
us to assess the demand and determine the needed number of providers 
and appropriate level of staffing to assist the Phoenix VA in 
successfully eliminating the initial backlog by the end of August 2014.
    Beginning in the summer of 2016, we conducted demand capacity 
assessments with nearly every VAMC within our PC3 service area. Armed 
with the Demand Capacity Assessment Tool, we and the VAMCs in our 
geographic areas of responsibility worked together to assess demand and 
then map the supply of providers that would be needed in each community 
to supplement VA care. We met one on one with each VAMC to assess how 
many providers of each specialty would be needed in addition to the 
supply of providers working at the VAMC to meet the needs of Veterans 
in each geographic area. This included not only a projection of the 
demand that was already known to exist but also that which was 
anticipated to materialize. We then took the output of this data-driven 
process and started to tailor the network on a market-by-market basis 
to meet demand.
    We already have begun demand capacity assessments in CCN Region 4, 
are constructing the network build sheets for each of the markets and 
have formally launched the CCN Region 4 contracting effort.
    TriWest and VA continue to finalize implementation schedule details 
but are looking to April 7, 2020, when we will begin to operate under 
the CCN contract in Montana and Eastern Colorado, to be followed by VA 
converting the rest of the Region 4 geographic area to the CCN platform 
by July 14, 2020. We and VA are in the midst of implementing the new 
tools, systems and processes to make the next generation of our 
privileged work together a success; we have compared demand information 
so that we might effectively tailor the provider network for CCN to 
meet community care needs of the Veterans who reside in Region 4; and, 
we are underway with setting the network for the start of health care 
under CCN.

    Prior to the start of health care delivery, TriWest will 
demonstrate to VA several key capabilities:

      Appropriate toll-free lines have been established

      Callers can be routed to the correct call center 
representative

      Availability of Electronic messaging

      Highly functioning website capabilities

      Support for English and Spanish speaking and hearing/
vision impaired callers is available both telephonically and online

      Warm Transfer capabilities are available

    Following the start of health care delivery in Montana and Denver 
on April 7, 2020, TriWest will continue to work with VA to identify and 
implement lessons learned and refine processes, as needed, before 
continuing deployments across the region. In addition to our CCN Region 
4 transition efforts, TriWest also is working with VA and Optum to 
transition out of community care and urgent care services in CCN 
Regions 1-3. We have been working together closely to ensure this 
transition is as smooth as possible.

Remaining Focused

    As we move forward with CCN implementation, we will remain focused 
on addressing challenges, refining our processes and approach, and 
adding manpower where needed. Some early challenges we remain focused 
on addressing include:

      Timely Appointment Scheduling: The volume of care 
requests has been significant, with increased demand for behavioral 
health being the most substantial. This higher than anticipated volume 
has resulted in some Veterans seeking community care to experience 
appointing delays as it takes manpower to appoint and when demand 
increases substantially without notice, it creates complication.

      Claims Processing: Provider network development becomes 
complicated when there are claims processing challenges. We have worked 
very hard over the years of this work to get to a place of solid 
performance, but have recently found ourselves challenged in a few 
areas:

          o Late arrival of VA fee schedule: Providers are paid in line 
        with Medicare or a VA fee schedule, depending on the service. 
        Each year, we receive an update in the fee schedules. 
        Unfortunately, the 2020 schedule arrived unusually late which 
        necessitated that we backed up payment on nearly 400,000 
        claims. I am pleased to report that due to the hard work of 
        many, this backlog is within days of being completely 
        addressed, and we expect to return to achieving performance 
        standards within the next few weeks.

          o Emergency Room Claims: In an effort to effectively address 
        VA claims payment challenges, TriWest agreed to process and pay 
        emergency room claims for VA. VA notified providers across the 
        country to send emergency room claims to TriWest. However, in 
        order to process these claims, we must first receive 
        authorization from VA. The relatively short notice in this 
        process change has created some confusion and has resulted in 
        less timely receipt of the authorizations. Hence, we are 
        currently holding emergency room claims for which we have no 
        authorization from VA while we seek to gain them so that we can 
        process and pay the claims. We hope to have this resolved soon 
        so that this backlog can be remedied. This approach seemed 
        preferable to all versus denying claims and creating even more 
        challenge and delay for the provider community given providers 
        would have to otherwise refile the claims.

          o Urgent care facilities: In processing and paying claims for 
        this new benefit, we have determined that claims will process 
        easier by using an ``exclusion'' versus ``inclusion'' method 
        for the codes used for services. This change is being 
        programmed and will bring the claims processing performance to 
        the high standard we have worked hard to achieve for this 
        critical component of our work. It should be completed in the 
        next couple of weeks.

    We are working aggressively to address these challenges, in 
coordination with VA. Efforts to resolve these issues include:

      Close collaboration with VA to refine volume projections, 
along with implementation of an aggressive staffing and training plan 
to address appointing delays.

      A firm commitment to timely claims payment, VA assistance 
in addressing old/outstanding claims payment issues and engagement of 
congressional Members and staff to encourage apprehensive providers at 
the local level to consider participating to serve Veterans. We 
continue to collaborate very closely with VA to address the claims 
challenges discussed above, and we also are working very closely with 
our claims processor to eliminate any claims backlogs as quickly as 
possible.

      TriWest senior leadership engagement and outreach with 
key VA preferred providers to assist in closing remaining network gaps.

Conclusion

    Chairwoman Brownley and Chairman Pappas, Ranking Members Dunn and 
Bergman and Distinguished Members of the Health and Oversight and 
Investigations Subcommittees, I salute you for placing a high priority 
on the critical issue of ensuring Veterans have access to care - both 
within VA facilities and in the community - when needed. Our nation's 
Veterans are our heroes. They have risked their lives to protect 
American values and society, so when their lives are at risk here at 
home, it is our moral obligation to serve and protect them. They have 
had our back as a country, so now we should have theirs.
    It is TriWest's great honor to be engaged in this privileged work 
on behalf of a grateful nation. The partnership between VA and TriWest 
has progressed and matured substantially over the past 6+ years. It is 
a dynamic relationship in which we both continue to refine and 
strengthen operational processes, efficiencies, and communication. The 
work is complex and challenging, but those of us associated with 
TriWest and in VA all are very focused, and I am very proud of the work 
we are doing together and our accomplishments thus far. Working at the 
side and in support of the leadership of VA and the staff at all levels 
has been and remains a privilege. They are a group of very dedicated 
citizens working tirelessly and as solid partners to execute what you 
have envisioned as the future of VA, embodied in the MISSION Act. And, 
I am confident that the trajectory we are on will continue to improve 
this program in CCN Region 4 and provide the high-quality community 
care Veterans have earned and deserve.
    No health care system in the country has more expertise than VA in 
addressing the health care needs of Veterans. The work ahead should not 
be to reduce or replace the VA system, but to enhance it and to 
supplement VA care in the community, when and where VA determines 
necessary. After all, ensuring our Nation's Veterans have access to the 
full range of timely, high-quality health care services they need must 
be our collective mission. Meeting our Veterans' ever-growing demand 
for care is an urgent, life-saving priority. We owe it to those who 
have sacrificed so much for us to provide them with the best care 
humanly possible that affords our Veterans an opportunity to live a 
healthy, full life.
    Through our nearly quarter of a century operation in support of DoD 
and VA, we have developed crucial experience in helping these systems 
implement and mature their programs to provide timely and convenient 
access to quality health care services. We are committed to providing 
Congress our full support as we continue our work alongside VA, helping 
Veterans to access high quality care in the community. For us, this is 
sacred work. Our mission is to find and serve those in need, ensuring 
they have access to the right services and health care providers while 
also supporting community care providers fully as they serve the needs 
of our Nation's heroes.
    Together, we can succeed, and we must succeed in this mission, 
because our Veterans and their families deserve no less!
    Thank you.
                                 ______
                                 

                Prepared Statement of Patricia D. Horoho

Introduction

    Chairman Pappas, Chairwoman Brownley, Ranking Members Bergman, and 
Dr. Dunn, members of the Subcommittees, I am Patty Horoho, Chief 
Executive Officer of OptumServe, and I am honored to be here today to 
provide an update on our operations in connection to the implementation 
of the U.S. Department of Veterans Affairs (VA) Community Care Network 
in Regions 1, 2, and 3.
    On behalf of the more than 325,000 men and women of UnitedHealth 
Group who work every day to help people live healthier lives and to 
make the health system work better for everyone, thank you for the 
opportunity to discuss our partnership with the VA, Veterans and their 
families, providers, and each of you to ensure that our Nation's 
Veterans have timely access to the best care available, whether inside 
the VA health care system or in their local community. Together, we are 
committed to serve those who have served this great Nation.
    In short, Optum is on track with our phased implementation plan:

      Thousands of Veterans are actively utilizing our high 
quality and broad Community Care Network;

      Providers are promptly getting paid for the care they 
deliver to Veterans;

      Our customer service channels are quickly answering 
questions from VA Staff and community providers; and

      Using data and utilization patterns, we are continuously 
building and adapting our network and operations to meet the needs of 
Veterans and the VA.

Who We Serve: Our Deep Partnership with Veterans and Federal Agencies

    I was pleased to join Chairwoman Brownley, Dr. Dunn, and Members of 
the House Veterans Affairs Subcommittee on Health last fall to update 
them on our progress in serving our Nation's heroes through the 
Community Care Network. We appreciate the opportunities we have had to 
spend time with many Members of Congress and their staffs as part of 
our implementation of this important effort, and to introduce or 
reintroduce them to our organization.
    OptumServe is the Federal health services business of UnitedHealth 
Group. We bring together the unique capabilities of the entire Company 
with broad and deep experience in health care services, technology, 
data analytics, and consulting. We partner with the U.S. Departments of 
Veterans Affairs, Defense, Health and Human Services, and other 
Agencies to help modernize the U.S. health system, and improve the 
health and well-being of those they serve.
    OptumServe is honored to support health programs that touch 
virtually every point in a military service member's or Veteran's 
journey. It starts when an American son or daughter raises their right 
hand to take the oath, to ensuring a reservist is medically ready for 
deployment, to a disability exam when a service member transitions from 
active duty to Veteran status, and, now, to the Veteran receiving care 
through the VA from a community provider.
    Our leadership team at OptumServe is comprised of Veterans from 
every branch of service, and 50 percent of our Community Care program 
office staff are Veterans.

Optum's Role in the VA Community Care Network

    Optum is proud to serve as the third-party administrator (TPA) for 
the VA Community Care Network in Regions 1, 2, and 3, which includes 36 
States, the District of Columbia, the U.S. Virgin Islands, and Puerto 
Rico.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    Under these contracts, Optum is responsible for:

      Community care network of providers. Optum is leveraging 
its broad network and relationships across UnitedHealth Group, and 
beyond, to provide a robust provider network representing the full 
breadth of health and wellness services for the VA. We buildupon this 
foundation by contracting with preferred providers requested by our 
partners within the VA as well as providers who reach out to us 
directly informing us of their desire to serve the Veteran population.

      Claims processing. Optum is responsible for promptly 
processing claims from providers who care for Veterans as part of the 
VA Community Care Network. This function is critical to ensuring we 
sustain the high quality provider network we are building.

      Call center for VA staff and providers. VA staff and 
providers can contact the Optum call center to get questions answered 
about authorizations, claims, and other issues.

      A portal for providers, VA staff and Veterans. Optum 
operates an online portal where users can find additional resources 
including claims, explanation of benefits (EOBs), and referral 
information. Individuals can access the portal at 
www.vacommunitycare.com. Our portal is uniquely built for our users' 
needs, outlined in the chart below:

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


      Community Care Experience Teams. These Optum teams 
provide on-the-ground support and resources to VA Medical Centers and 
staff. One team is aligned to each region, and each team has a team 
leader, a nurse, a business analyst, and one Veteran Experience Officer 
(VEO) assigned to each Veteran Integrated Service Network (VISN) within 
the region. While not a requirement, these teams allow Optum to remain 
better connected with local VISN and VAMC leadership, and each of the 
VAMC community care offices in order to better meet the needs of the VA 
at the local level.

    Early on, we recognized the need to incorporate the voice of the 
Veteran to ensure we were well-positioned to meet their needs.
    We have spent considerable time with our VA partners and within 
Optum to better understand the processes and potential areas of the 
Veteran experience that could be improved. Through a process that 
identifies each step of the Veteran's experience (called journey 
mapping), we gained valuable insights into the process of getting care, 
and how the process could work better for Veterans, VA staff, and 
community providers.
    As part of this effort, one year before we were awarded these 
contracts, we conducted one-on-one interviews with 125 Veterans in 
their homes and places of work across five States, and completed a 
national survey of 5,500 Veterans, representative of the Veteran 
population. This enabled us to gain a deeper understanding of the 
experience and mindset of Veterans, and how Veteran status impacts 
health and health-seeking behaviors.
    We have used these insights to prioritize and take action. This is 
critically important because the experience a Veteran has while seeking 
and receiving care is often perceived to be as important as the quality 
of the care they receive. From the very first contact, the experience 
of care has to be positive, both for our Veterans and for providers.

Performance to Date: Meeting & Exceeding Our Commitments

    Optum is on track with our phased implementation plan.
    We completed the initial roll-out of Region 1 on December 10, 2019, 
and today we are currently operating the Community Care Network and 
billing operations in areas across all three regions. We are on 
schedule to achieve full health care delivery in all regions by June 
2020.\1\
---------------------------------------------------------------------------
    \1\ A full deployment schedule can be found on Optum's Community 
Care Network portal at www.vacommunitycare.com.
---------------------------------------------------------------------------
    At every stage of our year-long implementation, we have dedicated 
staff either on the ground, virtually or both, to train and assist VA 
Medical Center staff as questions arise. We also use a command center 
approach in close collaboration with the VA to monitor the progress of 
each deployment.
    The command center allows Optum and the VA to jointly ensure 
consistent and frequent communication with the VAMC sites to manage 
issues, and provide continued education and feedback to ensure the 
system tools and provider network are performing as intended, often 
making necessary adjustments in real time.
    The transition for each area to Optum as the TPA is deliberate and 
collaborative, with open lines of communication from the leadership 
level to local VAMC employees:

      Deployment preparation consists of twice monthly meetings 
with the VA Office of Community Care and the transitioning sites to 
ensure site-level and Optum provider network readiness. This includes 
reviewing detailed maps and analysis down to the county and zip code 
level, consulting with historical referral data and past volume to 
identify future network needs;

      Approximately 45 days prior to a go-live date, we have 
initial planning meetings with VAMC leadership. The network is reviewed 
again and validated, and issues or gaps in network are discussed;

      Approximately 14 days from the go-live date, our advance 
teams increase the intensity of training and communications. Network 
progress is reviewed with VA;

      During the go-live week, we host a joint command center 
in partnership with the VA that monitors progress in real time, and we 
also provide site-level support teams consisting of both Optum and VA 
staff at the local level. We provide additional coaching and retraining 
of VA staff on handling referrals as needed; and

      At the end of the go-live week, we provide formal exit 
briefs for each of the VISNs and then provide ongoing supplemental 
support, including frequent touchpoints with the sites, to ensure each 
VAMC is able to successfully transition to CCN and operate 
independently.

    But our work doesn't stop after Optum fully deploys in an area or 
region. Working with local VA staff and providers, we continue to 
adjust operations, and refine and add providers to the network.
    With this, I would highlight a few specific areas of our transition 
to date:

      Building a High-Quality Provider Network

    Central to the Community Care Network is a robust network of 
quality credentialed health care providers from which VA medical staff 
and Veterans are able to choose.
    Our approach to building the Community Care Network is twofold: We 
begin by leveraging the 1.3 million providers in the national 
UnitedHealthcare and Optum networks. And, we also recruit those 
community providers who have a history of working closely with VA 
Medical Centers and Veterans in order to give these providers an 
opportunity to continue to care for Veterans in their community by 
joining our new network. We are committed to including qualified 
providers in our network who want to see Veterans.
    Our on-boarding process for providers helps to ensure that VA CCN 
providers are both competent and qualified to provide the services 
within their practice specialty, which is a new requirement under the 
Community Care Network. For the first time in VA Community Care, all 
providers in the Community Care Network are now credentialed in 
accordance with nationally recognized standards set forth by the 
National Committee for Quality Assurance (NCQA), or the appropriate 
accrediting body, or credentialed consistent with Federal or State 
regulations. We also obtain primary-source verification of the 
provider's education, board certification, license, professional 
background, malpractice history, and other pertinent data.

    In Region 1 where we have recently completed the transition, Optum 
has built a network that includes 178,000 health systems and 
providers\2\ across 309,000 care sites.\3\

    \2\ ``Health systems and providers'' is a count of unique National 
Provider Identification (NPI) numbers that includes an individual 
physician practice, a hospital system, or a group of affiliated 
practices that may operate one or multiple sites of care.
    \3\ Data extracted on 2/4/2020.
---------------------------------------------------------------------------
    We recognize that network management is a dynamic process and 
networks evolve over time - as they routinely do in health care markets 
outside of those served by Government. When we complete a transition, 
our work continues. We continuously refine and build the network to 
meet the needs of the VA and Veterans. We add providers based on 
utilization, data, analytics, and interest of providers who want to be 
involved in Veterans' care.
    For instance, even though we have fully deployed in Region 1, we 
continue to add new providers to the network. Since December 10th, when 
our deployment was complete, our network has grown by an additional 25 
percent. This represents 35,000 additional unique health systems and 
providers over 62,000 sites of care now available to the VA in just 
Region 1.\4\
---------------------------------------------------------------------------
    \4\ Data extracted on 2/4/2020.
---------------------------------------------------------------------------
    Our networks will continue to evolve and adapt to meet the needs of 
Veterans. This will continue in every area in which we are privileged 
to serve Veterans.

      Ensuring Prompt Payments for Providers

    In addition to delivering a high-quality provider network, we also 
recognize the need to implement a world-class experience for community 
providers. Central to achieving this goal is ensuring providers receive 
accurate, prompt payment for the health services they deliver. This is 
critical to the success of our network and vital to building trust 
between providers and our organization.
    With our contract partners, we have built a system that is easy to 
use and familiar to provider practices. By reducing administrative 
burdens, we are making it easier for providers to get paid accurately, 
and on time. Simply put, after a provider cares for a Veteran, they 
bill Optum, and Optum pays the bill.
    As of February 4th, Optum has processed more than 150,000 claims, 
and has paid claims in an average of 11.9 days with 99.93 percent of 
clean claims being paid within 30 days.\5\

    \5\ Across all regions where Optum is live.
---------------------------------------------------------------------------
    Beyond the data, providers have been expressing appreciation for 
making the billing and payment system easy to use to quickly get paid 
for the services they provide. As a restless organization, we 
continuously evaluate how we do business. We take in feedback from all 
our stakeholders and strive to optimize our processes and to 
communicate more.
    And when questions do arise, as they do with any new program, we 
work closely with providers to quickly resolve these issues.

      Communicating with Providers With Clear, Actionable 
Information

    Optum utilizes a number of different channels to communicate with 
providers. It begins during the initial contracting phase, and it is 
sustained through when they are a confirmed network provider. Key 
touchpoints, among others, include:

      Sending letters to providers currently in the 
UnitedHealthcare and Optum networks on the opportunity to participate 
in the Community Care Network and action necessary;

      Calls and letters to providers not already participating 
with UnitedHealthcare or Optum with the opportunity to participate in 
the Community Care Network and action necessary;

      Calls, letters, and in-person meetings for targeted 
health systems and providers with large footprints in local and 
regional areas;

      Personally reaching out through letters, calls, and 
meetings with providers identified by VA and others as high-priority to 
recruit into the Community Care Network;

      Following recruitment and credentialing, we provide a 
number of trainings on how the new Community Care Network works. This 
is done through in-person meetings, webinars, provider expos, and 
virtual town halls;

      Just prior to the go-live date in a particular area, 
Optum contacts providers again and provides information on where and 
how to submit a claim; and

      Regular updates, educational material and on-demand 
videos are also available on our provider portal at 
www.vacommunitycare.com.

    And, if a provider has a concern that needs to be addressed, our 
goal is to resolve that issue as quickly as possible through our 
customer service channels.
    We are restless in our desire to do more. We are committed to 
identify new and effective methods to communicate with providers.

      Providing Timely Customer Service to Community Providers 
and VA Staff

    A knowledgeable and responsive customer service operation is 
essential when VA staff or providers have questions about the new 
Community Care Network. Our dedicated team is available to answer 
questions about authorizations, claims and other issues.
    Through February 4th, we have received more than 35,000 calls to 
our customer service center, with an average speed to answer of 3.6 
seconds and 99 percent of calls are answered within 30 seconds. And, 
our customer service staff has resolved more than 99 percent of issues 
from providers and VA staff during the first call.
    We will continue to focus on providing quality customer service to 
providers and VA staff who need assistance.

Conclusion

    We appreciate the opportunity to address the Subcommittees today to 
outline Optum's role in assisting the VA with its mission to provide 
world-class health care to our Nation's Veterans.
    We also appreciate the leadership of these Subcommittees, Congress, 
and the VA, in envisioning a program that provides a phased approach to 
implementation in order to ensure a successful transition for VA staff, 
contractors, providers, and most importantly, for Veterans.
    We understand that health care is local and this phased approach 
enables us to work closely with the VA, VA Medical Centers, and others 
to deploy our network and capabilities, and ensures success based on 
the readiness of particular sites, while accounting for relevant local 
factors.
    Leading our collaborative efforts to care for our Nation's Veterans 
is the privilege and responsibility of a lifetime. As a Veteran; 
retired Soldier; former Army Surgeon General and Commanding General of 
the U.S. Army Medical Command; wife of a Veteran: daughter of a Veteran 
who served honorably in World War II, Korea, and Vietnam; and now the 
proud mother of an Army Infantry Airborne Officer; I assure you we are 
fully committed to the success of the VA Community Care Network and 
OptumServe's role in ensuring access to care for our Nation's Veterans. 
We are vested in this mission and know that mission failure is not an 
option.
    Thank you for the opportunity to be here today. I look forward to 
your questions.
                                 ______
                                 

                 Prepared Statement of William A. Dombi

    Since 1982, the National Association for Home Care & Hospice (NAHC) 
has been the leading association representing the interests of home 
health, hospice, and home care providers across the Nation, including 
home caregiving staff and the patients and families they serve. Our 
members are providers of all sizes and types--from small rural agencies 
to large national companies--and include government-based providers, 
nonprofit voluntary agencies, privately owned companies and public 
corporations. The provision of high-quality, life-enhancing care to 
vulnerable individuals and education and support to their loved ones is 
central to our collective purpose. We welcome the opportunity to submit 
testimony for the record for a hearing before the House Committee on 
Veteran's Affairs, Subcommittees on Health and Oversight and 
Investigations on ``MISSION Critical: Examining Provider Relations 
During the Transition to VA's New Community Care Program,'' and to 
provide our views on key issues related to The operation of the VA's 
home care benefit programs.

Home Care Benefits in VA Health Care

    The Veteran's Administration health care benefits for home-based 
care present one of the most robust arrays of supports for care in the 
home of any government health care program, far exceeding Medicare 
supports and rivaling even the best Medicaid program for home and 
community-based care. The benefits include skilled home health care, 
homemaker& home health aide care, hospice care, respite care, 
palliative care, home-based primary care, remote monitoring care, 
Veteran-Directed care, and adult day health care. https://www.va.gov/
GERIATRICS/pages/Home_and_Community_Based_Services.asp.
    While the exact number of veteran's receiving such services is not 
readily known, we estimate that it is nearly 1 million veterans of all 
ages. As such, the array of benefits shows a strong commitment in the 
VA to provide significant and unrivaled home-based care opportunities 
for this Nation's veterans. There can be no doubt that the VA is a 
leader in providing cost effective, high quality, and innovative health 
care services in the home.
    While designing a package of home care benefits for veteran's is an 
important step to meeting their health care needs, it is equally 
important that the benefits be implemented in a timely and effective 
manner. The transition to the new Community Care program demonstrates 
that proper implementation planning and execution can make a dramatic 
difference in delivering on the promise of home care services. At 
present, there is a great deal of room for improvement in the VA's 
transition to Community Care. We do emphasize that the VA and its 
contractor, Optum, are working hard to bring about full implementation 
of the home care benefits as part of Community Care. Unfortunately, the 
outcome continues to fall short of what our veteran's deserve. However, 
there is time to learn lessons from the early stages of the Community 
Care transition to establish implementation modifications and 
improvements as the transition continues to unfold.
    In that respect, we can only speak to experiences in home care 
programs. We sincerely hope that home care is an anomaly in the 
implementation of Community Care. Still, in terms of the home care 
programs, the implementation issues cover several important aspects of 
health care access and delivery. The issues that have surface involve:

          1. Confusing communications
          2. Securing an adequate supply of care providers
          3. Care authorization
          4. Payment delays
          5. Payment rate cuts

    Each of these subject areas are addressed in more detail below.

Communications

    NAHC members report ongoing difficulties in gaining an 
understanding of what is changing through Community Care, who is 
responsible for the various parts of the transition to Community Care, 
and how the care authorization process and provider enrollment process 
is supposed to work.
    Today, a starting point in communications is the website of the 
government agency. To the extent that comprehensive information about 
the Community Care transition is available on the VA website, it is 
very difficult to uncover. For professional providers of care, a 
crucial linkage for patients, the website navigation is very confusing 
and appears to offer information only through laborious searches that 
depend on knowing the right key words. Once a party gets past the 
scanty description of the home-based care benefit package, it is near 
impossible to find the detailed information need to determine what is 
needed for an existing VA home care provider to qualify to provide 
services in Community Care. For veterans, it is seemingly impossible to 
determine how to access home care benefits in the new program model.
    NAHC recommends that the VA undertake a wholesale evaluation of its 
website and to initiate revisions that provide for improved navigation 
and content that answers these and other basic questions that exist in 
any heath care program.

Access to Providers of Home Care Services

    Across the country there are an estimated 30,000 providers of home 
care and hospice services. Of those, over 11,000 are home health 
agencies and over 4500 hospices participating in Medicare. The 
remainder provide Medicaid and private pay nursing and personal care 
services. Many of these providers had accepted VA patients into their 
care. However, due to changes connected to the transition to Community 
Care, many of these longstanding providers of care to veterans are now 
on the outside looking in, turning away prospective patients on a daily 
basis while waiting for months to complete a credentialing, 
contracting, and enrollment process long after the transition to a new 
contractor in Community Care has started its administration of the home 
care benefits.
    The difficulties experienced by home care providers is well 
explained by Sheila Rush in a recent email to NAHC. Ms. Rush is the 
owner of a home care company, Nurses Care, Inc., operating in Ohio.

        Our agency, Nurses Care, Inc, receives referrals for home care 
        for veterans from the VA, ordinarily several in 1 week, 
        sometimes several in 1 day. We care for the vets in the Dayton/
        Cincinnati region. As of Dec 10, 2019, the VA office from where 
        our referrals normally come told us that we are not on the 
        provider list, so they cannot give us referrals unless it is 
        for a vet that we have previously cared for through VCA or 
        Triwest. We contacted Optum on Dec 10 to find out why they do 
        not have us as a Provider.

        A little background: Prior to this, I was sent a Contract to 
        sign on June 21, 2019, via email from Coletta Lloyd, VA Network 
        Contractor, United Healthcare in St Louis, with instructions to 
        sign and mail to this address: United Healthcare, 780 Shiloh 
        Rd, MS-1.700, Plano, TX 75074, so that we could continue to be 
        a Provider for the VA. I signed the contract and mailed the 
        same day. I also emailed Ms Lloyd a copy of that signed 
        Contract.

        When informed by our VA office that we could no longer receive 
        referrals as of Dec 10, I contacted the Optum phone number 
        (888) 901-7407 to find out why we are not in the system. I was 
        told they would escalate our complaint, and they would call me 
        back within 5 days. They gave me a Case Id #. I called Coletta 
        Lloyd who then called Optum and forwarded my signed Contract to 
        the Optum office on Dec 10, so I know they have had our signed 
        Contract since Dec 10.

        They told her our case was being escalated. We have never 
        received a call back. I now have called Optum ten times over 
        the past month, only to be informed the exact same thing every 
        time, our case was being escalated and they would call back 
        within 5 days.

        Today I called the VA customer service center and explained to 
        her our situation. She called Optum with me on the line and 
        asked for a supervisor. We again explained our situation, and 
        were told, ``We have a Contract signed by you on Dec 16 that we 
        received on Dec 10. We are just waiting for it to be downloaded 
        into the system.'' I informed the girl that I signed the 
        Contract on June 21, and asked how she could have received a 
        Contract on Dec 10 that was signed on Dec 16. I asked her to 
        forward it to me. She stated that she was only reading notes in 
        my file. They promised to call back by noon tomorrow, Jan 9. 
        So, the same run-around again.

        We received 107 VA referrals in 2019. What is going to happen 
        to these vets in 2020? The VA Dayton loves working with Nurses 
        Care, because we cover a large area and get out to see the 
        patient the day of or the day after the referral. We spoke with 
        them again today, and they have been instructed that, as of Jan 
        10, they can no longer give us any referrals unless we are in 
        the Optum system as a Provider, not even patients that we have 
        had in the past. I don't understand why we can't continue to 
        see the vets under Triwest. Is there anyone who can help us?

        Update 2/6/20--The Dayton VA contacted us to let us know that 
        Nurses Care is showing up in the Optum system! The Dayton VA 
        has been sending us referrals under Triwest, which they had the 
        approval to do until Feb 8. The last few weeks we have received 
        a few Triwest, VCA, and now Optum referrals. Our next issue is 
        trying to make sure that we get paid as promised.

    The good news is that Nurses Care, Inc. is finally an approved home 
care provider. It took many months of confusion to work it all through. 
That is not an appropriate experience for a longstanding VA home care 
provider. A different outcome is affecting another home care provider.

        ``We are a small independent home care agency with a census of 
        85. 64 percent of our clients as veterans. When the transition 
        to Triwest occurred, we were required to credential with them 
        rapidly but not required to have a contract. This transition 
        happened in late February 2019. We heard about the upcoming 
        transition to Optum and have been reaching out to them to 
        ensure our clients will continue to be cared for. As of this 
        date, we have not received any official word from Optum when 
        this transition will take place. The local VA office continues 
        to provide authorizations for Triwest , however Triwest is slow 
        to pay resulting in RAPS being autocanceled and claims being 
        rejected. It has been a living nightmare! Currently Triwest 
        owes us close to $300,000 for services rendered. Multiple 
        attempts to collect have fallen on deaf ears or pass the buck 
        scenario happens. The local VA doesn't appear to have any clue 
        what is happening as well. We are the only home care agency 
        that will provide care to our local veterans but will soon be 
        forced to discontinue doing so.'' Greg Leivishka (Dove Home 
        Health Professionals

    NAHC is also aware of significant problems on the credentialing and 
enrollment loading phases involving multiple home health providers that 
operate throughout the country. Despite significant time and resources 
put into resolving the issue, nearly 250 of those locations are still 
outside the Optum system. Many of these locations are some of the 
highest quality home health agencies in the country according to the 
Medicare Home Health Compare website presented by the Centers for 
Medicare and Medicaid Services (CMS).
    As the transition to a new VA contractor occurs across the country, 
NAHC recommends that the VA consider revising the provider enrollment 
process to avoid a loss of access to care, improve the options 
available to the veterans, and ensure that patients' needs are 
prioritized over paperwork. The revisions could follow a path travelled 
by a number of State Medicaid programs when those programs transitioned 
from a ``fee for service'' program to Managed Long Term Services and 
Supports. There, the transitions permitted: 1.) beneficiaries to 
continue receiving authorized services from their existing provider for 
6 months or more; 2.) grandfathering in existing home care providers on 
a provisional basis while undertaking any desired credentialing and 
contracting; and 3.) maintaining pre-existing payment rates for a 
designated period of time. This manner of programmatic transition 
secured near seamless experiences for patients and providers alike 
without creating any significant difficulties for the State or its 
contractors.

Care authorization

    A longstanding problem with VA home care, care authorization, 
continues in Community Care. With this issue, it appears that the 
causation lies with the VA rather than its contractors. Here are some 
of the reports we have recently received:

      ``we are having much difficulty getting VA physicians on 
a timely routine of signing our orders prior to billing.''

      ``At this time we are having an issue with getting our 
Auths form the VA in Newington CT in a timely manner, we are still 
waiting on auth from 10/1/2019 and we need them in order to bill its 
now 1/8/2020.''

      ``Another issue with VA is receiving authorizations for 
Community Care Services such as homemaker and HHA services. We receive 
the referral and begin services but it may take 6 months or more before 
we receive the authorization. We must have the Authorization number 
before we can bill so we have to wait for 6 months or more before we 
can bill.''

      ``I am a director in Nebraska and we are having a very 
difficult time with getting a straight answer regarding who are to put 
in as a payer...all our auths are coming in a VA Care in the Community, 
but they have stated that VA is now a PPS payer and that they should 
have been with Triwest...we were never told that and they are saying 
that Optum is not ready until at least March to begin paying...my 
billing company hasn't received a straight answer from anybody at the 
VA regarding who should be put in as a payer...please advise...thank 
you!''

      ``We are having similar challenges with the Rodebush VA 
in Indianapolis, IN. Claims that are directly being paid thru the VA 
Hospital are just very slow to pay and deny for erroneous reasons such 
as incorrect bill type. We then have to fax our dispute and it appears 
they only have one person processing all home health claims and 
researching errors. Therefore the timeliness of payment resolution is 
poor.

        In addition, authorizations are a challenge especially for 
        clients that need additional authorization. Receiving the 
        necessary paperwork is always behind therefore we have to see 
        the client prior to receiving the authorization.

        Referrals with authorization / claims going to contracted 
        party, TriWest and/or Optum , is also a challenge because even 
        if the referral/initial auth states TriWest or Optum, many 
        times they are not even aware of the client. So we have to 
        assume the VA is not notifying them. We start service on the 
        client but do not have the ability to get reimbursed. Many 
        times, necessary information required by the third parties such 
        as referral numbers are not being given to us on the forms 
        either.

        I am in discussion on all of these issues with Rodebush VA but 
        at this time these are still current issues.''

      ``The owner at this time has stopped taking any New VA 
patients until they VA can get our auths to us faster.''

    In the absence of care authorization, care cannot start. In the 
absence of a start of care, the veteran is at risk of an acute 
exacerbation of his/her condition that may necessitate much higher cost 
care than home care. In some circumstances, the absence of a care 
authorization can jeopardize the life of the veteran. NAHC respectfully 
recommends that the VA take immediate steps to expedite home care 
authorizations. Alternatively, the VA can rely upon the judgment of 
those professionals caring for the veteran and cover care a certified 
necessary by the attending practitioner.

Payment Delays

    For those patients and providers fortunate enough to secure home 
care authorizations, the trials and tribulations are just beginning. 
Payment delays abound. Here are a few recent comments from NAHC 
members:

      ``We are just starting to get pd now 97 days out''

      ``A lot of the claims starting May 19 has not been paid 
due to VA internal workings.''

      ``We ... have been providing services to the VA since 
2009.

        Over the last few years, our payments have become slower and 
        slower with more and more denials. In the last year or so, 
        there was a major change in the VA and they moved the billing 
        staff from Orlando to Tampa, and now we cannot even reach 
        anybody there anymore.
        Despite all this we continue to serve the veterans because we 
        don't want to see them suffer more than they are already.
        It has come to the point where we are owed more than $250,000 
        by the VA, which as you can imagine is putting a major 
        financial strain on our operations, and we are afraid that we 
        will either need to close down or cease serving these veterans 
        if these issues do not get resolved shortly.''
      [We] ``made the very difficult decision to discharge 18 
of our VA patients after endless talks with UHC, the VA and OPTUM. We 
were unable to come to an agreement or get an answer in regards to 
payment. We had never switched to TriWest - the VA agreed to keep 
paying us directly so we did not lose money there. We did see patients 
into the time were supposed to bill Optum. I am not sure that we have 
received anything from them yet. We were all heartbroken for the 
patients who were picked up by an agency that many were not happy 
with.''
    No business can carry receivables for an extended period of time. 
Home Care companies in particular do not have the capital to manage 
unpaid bills for services as they are not ``brick and mortar'' 
institutions. Instead, they operate on human capital with payroll due 
every week. NAHC recommends that the VA establish a clean claim payment 
deadline. Failure to meet the deadline should require the payment of 
interest on the amount owing equivalent to the interest level Federal 
debtors pay under the Federal Claims Collection Act.

Rate Cuts

    Once a provider completes the myriad of pathways to provider 
enrollment, its challenge turns to care authorization. From there, the 
adventure shifts to payment delays. When payment finally arrives, it is 
not a pleasant surprise. Here are recent experiences:

      TV News Story in Vermont and New Hampshire - Rates cut in 
half. That led to discharge notices being sent to veterans the 
providers were caring for. https://www.wcax.com/content/news/Last-
minute-deal-saves-home-care-services-for-veterans-in-Vt-NH-
566788631.html

      ``I received a call from VA stating that there was an 
oversight on the rates that were released by the central office. I was 
told yesterday that they have updated the rates and will be released to 
us shortly. The new rates for S5130 are $27.12/hour, however, no change 
in G0156 at this time. This updated rate agreement is for all community 
care providers is my understanding.''

      ``After our Board Meeting last Thursday, I came back to 
the Office and checked the VA Optum rates and none of them covers our 
costs. So I contacted the VA, VA Optum, Joanie Ernst, Chuck Grassley 
and Abby Finkenour. I let them know that no Home Health Agency will be 
able to treat veterans who have the unbundled VA Optum and we will have 
to discharge all of them.

        I got a response from both the VA and VA Optum and they said 
        they need to set up a meeting with each other to discuss this . 
        . . not sure when this will happen.

        I also got a response today from Joanie Ernst and Abby 
        Finkenauer's Office and I gave them specifics. Here is an 
        example:

          o VA Optum pays 6.88 per unit for a bath aide. Our Aides 
        typically spend 30 minutes for a bath; therefore VA Optum would 
        pay us 13.76 per visit. We pay our Home Health Aides $18/visit.

          o VA Optum pays 29.92 per unit for Physical Therapy. Our PT's 
        typically spend 30 minutes for treatment; therefore VA Optum 
        would pay us 59.84 per visit. We pay our contract therapy 
        company $92/visit.''

    One message puts it all together well. It comes from Diana Taylor 
of Freedom Home Health Care in Iowa.

        We need help from NAHC. We received this information last week 
        that our rates are being drastically cut and also in 15 min 
        increments. And get this it went retroactively to November 1, 
        2019 claims. This hit my company hard, there is talk of a 
        proposed increase but we need some advocacy to keep rates the 
        same til they get something figured out. I will need to begin 
        lay offs the end of this week. This is way worse than any PDGM 
        issue for us, this was a surprise.

    Below is a copy of a letter I sent out to Legislators.

        Allow me to introduce myself, I am Diana Taylor owner of 
        Freedom Home Health Care. In the event you are not aware the 
        Home Based Community Care program has not been able to meet the 
        needs of its Veterans in the Des Moines Metro and surrounding 
        area. For the past 10 years, Freedom Home Health Care has been 
        a contracted provider of nursing, home health aide, homemaker, 
        and respite. In fact, the VA Home Based Community Care does not 
        even employ persons to provide Home Health Aide, Homemaker, or 
        Respite. We are the VA's most utilized sub contracted home care 
        service. In fact, I have been proud to say that 60 percent of 
        the clients we serve are Veterans. We have proudly stood by the 
        VA through the transition of VA Choice, then TriWest, and now 
        Optum. Not one Veteran has gone unserved or underserved during 
        this transition despite the fact that this billing mess means I 
        have not been paid on claims for services I provided in August, 
        September, October, November, and December. The VA has been as 
        far as $200,000 in debt at one time to Freedom Home Health Care 
        as we patiently wait for the VA to sift through the mess of 
        this transition.

        I was given notice yesterday, that our rates have dropped 
        drastically without any warning. Services are paid for in 15 
        minute units. Our particular agency was paid, $11.61 per unit 
        and now the new RETROACTIVE rate is $6.88. Yes retroactive. 
        Waiting to be paid on claims is a huge hindrance for my 
        company. But I just found out for all services that I provided 
        since Nov.1, 2019 I have had drastic unforeseen cuts from my 
        contracted rate.

        As a provider, I am required to be Medicare Certified, and to 
        hold that certification the Federal Government requires that I 
        give Patient Rights. One of the rights is letting them know 
        verbally and in writing the charge for services prior to 
        providing a service and prior to a change. Hence, I believe as 
        a provider of a government contract I should be afforded at 
        least the same right. I understand that other home health care 
        agency in other parts of the State have already given notice to 
        their clients that effective Feb. 1, 2020 they will be 
        discharged from their services due to the new rates. I do not 
        want to do that to our Veterans, I want to hold out to see if 
        the pending/proposed rates go through. I do not want to let our 
        Veterans down because they certainly have not let my country 
        down.

        However, I want there to be understanding of the effects of 
        this reimbursement change. So consider the following:

        A Veteran is incontinent of urine, and in order to shower and 
        get dressed they need a home health aide. It takes 30-45 
        minutes to give a bath but for the sake of this example, we 
        stay a full hour. Our new surprise rate is $27.52 per hour.

            a) Average wage of a HHA is $17/hr

            b) McDonalds website advertises $10/hr

            c) Minimum wage $7.25

        ******Key Concepts: Cost for that 1 hour bath visit

              1) $17 for direct wage

              2) Add 30 percent to cover employment tax FICA, FUTA, 
        SUTA, and Work Comp = $5.10

              3) Average mileage between clients 10miles paid to staff 
        at (lower than allowable IRS) 48 cents per mile = $4.80

              SO FAR This visit costs me $ 26.90 and I haven't even 
        figured in the cost of administration, billing, and providing 
        health and liability insurance.

I AM PAYING YOU TO TAKE CARE OF A VETERAN.

    This table represents the new ``surprise rate'' versus the 
proposed. I am asking you to consider this as an emergent need and 
provide immediate support to at a minimum restore previous rates till 
you consider the Pending.
    I truly cannot sustain this business relationship with the VA 
without immediate intervention.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


    Rate cuts of this nature have the natural and foreseeable effect of 
lost access to care. NAHC has been informed that it is the VA that sets 
payment rates, not the contractor. We have also been informed that 
rates are based on Medicare rates where such exists for the type of 
service involved. The reality of rate setting is that it appears to 
occur ``behind the curtain,'' leaving patients and providers often in 
the dark. NAHC recommends that the VA (and its contractors where 
applicable) maintain a transparent rate setting process that is focused 
on real life care costs and the level of payment needed to ensure 
uninterrupted access to care.

Conclusion

    We greatly appreciate the opportunity to provide the Committee with 
the foregoing information. We stand ready to partner with the VA and 
its contractors to develop all necessary steps to ensure a viable home 
care program fully accessible to our Nation's veterans.
                                 ______
                                 

                 Prepared Statement of Erik L. Golnick

Introduction

    Good afternoon Chairs Pappas and Brownley, Ranking Members Bergman 
and Dunn, and Members of the Subcommittees. Thank you for inviting VFR 
(Veteran and First Responder) Healthcare to testify today regarding our 
experience as a community provider working with the Veterans Health 
Administration (VHA) and its third-party administrators (TPA), 
OptumServe and TriWest Healthcare Alliance. As a former Naval Officer 
who suffered from Post-Traumatic Stress after my separation from the 
Navy, I am acutely aware of the importance of advancing and improving 
Veterans' access to health care and I thank you for the hard work these 
Committees do to ensure care for our brothers and sisters.
    VFR Healthcare, along with our sister organization Strive Health, 
is a Veteran-owned and operated organization that was founded to 
increase the access to, and quality of, outpatient substance abuse and 
mental health treatment for Veterans, First Responders, and their 
families. Our clinical and medical leadership team, all of whom are 
Veterans, developed trauma-informed clinical programming designed to 
address the specific issues and unique needs, preferences, and values 
of Veterans, first responders, and their families.
    Our network of Centers for Recovery and Community Health utilize 
this population-specific clinical programming and provide a wide range 
of trauma-informed, evidence-based treatment programs and services for 
individuals and families suffering from substance use and mental health 
disorders. In addition to providing behavioral health services, we are 
dedicated to promoting community collaboration to increase all 
Veterans' access to mental health as well as other health resources.
    In June 2018 we entered into a partnership with the U.S. Department 
of Veterans Affairs to enhance Veterans' access to substance abuse and 
mental health services to reduce suicide. Since then, we have been 
working together to advance and improve Veterans' mental health and 
well-being and expand and promote community collaboration to increase 
all Veterans' access to mental health and substance abuse resources. 
Through this partnership we have been able to successfully enhance 
Veterans' access to behavioral health care, which is evidenced by the 
fact that 100 percent of Veterans referred to any of our treatment 
programs could have scheduled an intake within 24 hours.
    We are honored to be partnered with VA and have had the privilege 
of providing behavioral health treatment services to Veterans over the 
last few years. In doing so, we have had the unique experience of 
working with VA and providing health care services to Veterans through 
several different community care programs, TPAs, and transitions.

Challenges with Community Care

    As a Veteran-run Community Care provider, we are mission focused on 
ensuring that Veterans and their families are getting the highest 
quality care that they need in a timely and efficient manner. As such, 
we assume the administrative burden on behalf of the Veterans we serve 
and deal with any issues with referrals, authorizations, and billing. 
Taking on the administrative burden for Veterans is especially 
important in mental health and substance use treatment as these 
administrative issues can cause stress and anxiety for the Veteran at a 
time when stability and structure in their lives is the difference 
between life and death.
    Now, before discussing our experience and challenges we have faced 
as a community provider working with the TPAs I believe it's important 
to note that VFR Healthcare is contracted with over 15 separate 
commercial health insurance plans as well as two State Medicaid plans. 
The challenges we have experienced with the TPAs are not unique and 
unfortunately happen quite often with other health plans during a 
period of transition. It is our hope that illuminating these issues and 
providing some insight as a community provider, we can assist in making 
the Community Care Network more efficient as well as the transition to 
other regions easier.

Challenges

    First: Clear Delineation of Roles, Responsibilities, and Trouble-
Shooting Processes

    I will provide an example that clearly highlights this challenge. 
In this instance, we received a complete and accurately authorized 
treatment referral from a VA Medical Center. The authorization covered 
the provision of intensive mental health treatment services for a 
Veteran-beneficiary, which were not immediately available through VA or 
through its other contracted providers of care.
    We began providing care upon receipt of the authorized referral 
from VA, granting access to the specific modalities and services, which 
were critical for the treatment and well-being of the Veteran. After a 
few weeks we began receiving denial of claims from the TPA, stating 
there was no authorization on file. We followed protocol and spoke with 
a TPA employee who said that: (i) no authorization existed in the 
system for this Veteran; and (ii) even though we had a copy of the 
authorization in-hand, we would have to contact the community VAMC to 
resolve the issue.
    We subsequently spoke to the local VAMC official, who stated that 
all proper steps were followed, and this was an issue on the TPA side. 
We then contacted the TPA a subsequent time, to no avail. This 
continued for two additional rounds of escalations from both the TPA 
and VA, each unable to apparently resolve this impasse. All the while 
we continued provision of care - the Veteran and their well-being must 
come first in our view. It has been almost a year since this issue 
began and we are no closer to resolving this matter.

    Second: Ensuring a Seamless Referral Process

    We have spent considerable time with our VA partners and with the 
TPAs to better understand the referral processes and potential pressure 
points. While the new CCN allows VA staff to refer Veterans directly to 
community providers, in practice there are several pressure points 
where a referral can be slowed down or ``stuck.''

    Third: Efficient and Accurate Uploading to the TPA System

    A complete and accurate upload of a community provider to a payer 
system is critical to ensuring that proper referrals are generated, 
claims and payments are appropriately paid, and accurate information is 
provided to Veterans and referring providers through the VA. Any issues 
with this upload present dire consequences to the community provider 
and significantly affects the care currently being provided as well as 
the care coordination with VA.

    Fourth: Uniform Claim Submission and Reconsideration Policies

    Claim forms, which healthcare providers submit to get paid for 
services rendered, are extraordinarily complex and comprehensive. As 
such, setting and adhering to uniform claim submission and 
reconsideration policies is paramount to ensuring that claims and 
payments are appropriately paid and erroneously denied claims can be 
resubmitted and properly adjudicated in a timely manner.

Conclusions

    We appreciate the opportunity to address the Subcommittees today to 
assist VA and the TPAs with their collective mission to enhance the 
health and well-being of our Nation's Veterans. We believe the 
Community Care Network is critically important to ensuring Veterans can 
access the necessary care in a timely manner. As such, it is imperative 
that processes, systems, and controls are in place so VA, the TPAs, and 
community providers can work seamlessly together to enhance the access 
to care for Veterans.
    While community providers like us are bearing the brunt of these 
challenges in the near-term, they are not unique to VA or the TPAs and 
we believe they are solvable challenges. We are confident that VA and 
the TPAs will work diligently to resolve these issues and on a go-
forward basis VA, the TPAs, and community providers will work together 
as a more efficient team to ensure that Veterans receive timely and 
adequate care.
    Chairs Pappas and Brownley, Ranking Members Bergman and Dunn, and 
Members of the Subcommittees, this concludes my statement. We would be 
happy to answer any questions you or other members of the Subcommittees 
may have.

                       Statements for the Record

                              ----------                              


         Prepared Statement of Health Net Federal Services, LLC

    Kathleen E. Redd is the President and Chief Executive Officer of 
Health Net Federal Services, LLC (HNFS), a wholly owned subsidiary of 
Centene Corporation, a national leader in publicly financed health 
care, including Medicare, Medicaid, and state-sponsored health care 
programs. In this capacity, Ms. Redd is responsible for the strategic 
direction and management of both HNFS and MHN Government Services, a 
subsidiary specializing in behavioral health care services in support 
of Federal programs. Ms Redd became President and CEO in June, 2018.
    An industry leader in developing large-scale, federally managed 
health care programs, HNFS is a health care solutions company that has 
provided high-quality, cost-effective managed health care programs and 
behavioral health services to public sector employees and beneficiaries 
for over 31 years.
    We appreciate the Committee's focus on provider relations for the 
Department of Veterans Affairs' (VA) contracts.
    At a time of crisis, HNFS stepped in to assist the VA in securing 
critically needed medical care for our Nation's heroes as a supplement 
to in-house VA patient care. In 2013, HNFS proudly began managing the 
Patient-Centered Community Care (PCCC) Program in Regions 1, 2 and 4. 
Our work expanded to the Veterans Choice Program (VCP) in these regions 
in 2014. As the need for urgent medical care was acute, VCP began only 
90 days after the Veterans Access, Choice and Accountability Act was 
approved. Nearly one million veterans received expedited care through 
HNFS' administration of this contract with over 1.7 million referrals 
processed. HNFS' contracted duties with VA to manage care under PCCC 
and VCP were transitioned back to VA on Oct. 1, 2018.
    Thousands of community providers across our VA-contracted regions 
(37 states and the District of Columbia, Puerto Rico and the U.S. 
Virgin Islands) answered the call to action and quickly responded to 
provide our veterans the care they needed and deserved. We are thankful 
to our provider network for their patriotism and the value they 
provided. It is critically important that we ensure our providers are 
paid for the services they rendered under the PCCC and Choice contract, 
in accordance with the terms and conditions the VA established. Since 
early 2018, we have worked with our providers and the VA and have 
increased our focus on reconciling provider accounts and helping them 
seek reimbursement either through HNFS or VA.
    Over the period of performance on the PCCC and Choice contract, 
HNFS has processed approximately 9.5 million claims. Our provider 
payments total approximately $2.7 billion. We will continue to support 
the effort to reimburse providers into the summer of 2020, ensuring 
appropriate payments are made to all of our providers who helped in 
this time of need. We are pleased to report that we are nearing 
completion of reconciling all of the claims we are responsible for from 
our PCCC and Choice contract. We anticipate all remaining claims to be 
processed and completed by the end of July.
    At the VA's request, and in good faith, we extended the original 
timely filing claims submission deadline of March 26, 2019 to Dec. 31, 
2019. As a result, with no action required by providers, we reprocessed 
approximately 35,000 claims previously denied for timely filing. 
Additionally, we accepted new PCCC/VCP claims for services performed 
through Sept. 30, 2018, for care authorized by HNFS. (A new claim is 
one that had not previously been received and processed by HNFS.)
    As of Jan. 31, 2020, our claims inventory is less than 20,000 
(14,000 new claims, 6,000 disputed claims) with expected provider 
payments of approximately $4 million. Much of the remaining claims 
inventory is complex and will require additional research to ensure 
appropriate payment and proper stewardship of Government funding.
    We are on schedule to complete our new claims inventory of 14,000 
by the end of February and our provider claims inventory of 6,000 by 
the end of July. Our claims reconciliation efforts include 
reprocessing, adjusting for additional payment and recouping 
overpayments, as appropriate.
    HNFS' team of claims experts has deployed a significant number of 
personnel to work both telephonically and onsite with many provider 
groups to resolve claims resubmission and payments in an effort to make 
the process easier for providers.
    As we approach the end of our work on the contract, we are 
committed to continue working with the VA and providers to pay any and 
all eligible claims to fulfill our contractual obligations and our 
commitment to our Nation's heroes. Additionally, HNFS has assisted the 
VA in identifying providers seeking assistance around continued 
confusion on where to submit claims that are associated with the 
current MISSION Act program contractor or the VA directly.
    As this committee knows, the Veterans Choice Program underwent many 
changes and faced many challenges: for veterans navigating care, for 
the VA, for providers as well as the administrators. We hope many 
lessons can be learned from this valuable program and that veterans 
will continue to receive the care they deserve, whether directly 
through the VA or in their own communities.
    We remain committed to supporting our Nation's military service 
members and veterans, and are happy to be a resource to the VA and the 
committee as you move forward with the Community Care Program.

About Health Net Federal Services

    Health Net Federal Services has a long history of providing cost-
effective, quality managed health care programs for government 
agencies, including the U.S. Departments of Defense and Veterans 
Affairs. For over 31 years, HNFS has partnered with the Department of 
Defense to provide health care services to the men and women who serve, 
and their family members. Health Net Federal Services was one of the 
first companies in the U.S. to develop comprehensive managed care 
programs for military families. In addition, HNFS provides quality 
behavioral health services for active duty service members, veterans 
and their families. Visit www.hnfs.com for more information.

About Centene

    Centene Corporation, a Fortune 100 company, is a diversified, 
multi-national health care enterprise that provides a portfolio of 
services to government sponsored health care programs, focusing on 
under-insured and uninsured individuals. Many receive benefits provided 
under Medicaid, including the State Children's Health Insurance Program 
(CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long 
Term Care (LTC), in addition to other state-sponsored/hybrid programs 
with the U.S. Departments of Defense and Veterans Affairs. Centene 
operates local health care plans and offers a range of health insurance 
solutions. It also contracts with other health care and commercial 
organizations to provide specialty services including behavioral health 
management, in-home health services, life and health management, 
managed vision, pharmacy benefits management, specialty pharmacy and 
telehealth services.

About Kathleen E. Redd

    Ms. Redd has over 30 years of experience in corporate financial 
management. Prior to joining Health Net Federal Services, LLC., Ms. 
Redd was the Vice President and Chief Financial Officer of Aerojet 
Rocketdyne Holdings, Inc., a New York Stock Exchange listed aerospace 
and defense contractor.
    In April 2019, Ms. Redd was named as an honoree for the Sacramento 
Business Journal's ``Women Who Mean Business'' Award. In 2012, she was 
one of the Sacramento Business Journal's ``Leaders of the Year'' and in 
2010, was named the Sacramento Business Journal's ``CFO of the Year'' 
in the large company category. Kathy is a certified public accountant 
and a graduate of California State University, San Jose.
    Headquartered in Rancho Cordova, California, Ms. Redd leads an 
employee base of over 2,000 across 44 U.S. states, two territories and 
17 countries across the globe who provide health care services to more 
than 2.9 million eligible military beneficiaries through the Department 
of Defense's (DoD) as well as our work with the U.S. Department of 
Veterans Affairs (VA).
                                 ______
                                 

Prepared Statement of Home Care, Hospice & Palliative Care Alliance of 
                             New Hampshire

    Congressman Pappas and Members of the Sub-Committee:
    Thank you for seeking public input regarding the transition to the 
Veterans Administrations' new Community Care Program. I am writing on 
behalf of the Granite State Home Health and Hospice Association, which 
represents home care, hospice and palliative care providers and the 
people they serve. Association members range from traditional non-
profit visiting nurse agencies (VNAs) to privately owned small 
businesses. These members are committed to providing compassionate 
medical care and personal care services that enable veterans to remain 
independent in their homes.
    Over the last several months, home care agencies have reported many 
problems related to the provision of care to veterans. In December, the 
Association conducted a survey of our members regarding VA clients. 
Sixteen agencies caring for approximately 350 veterans a year 
responded. These agencies generally serve patients from the Manchester, 
NH and White River Junction, VT VA Medical Centers. The reported 
problems vary among referring sites, suggesting a VA third party 
administrator system that lacks uniform standards and appears to be in 
disarray to providers on the front line of care. Here are some trends:

Backlog of Provider Payments

      All agencies reported payments in arrears for VA clients. 
The total payment backlog was over $550,000. While this may not seem 
like much to Congress, it can significantly impact cash-flow for many 
small agencies and affects their ability to participate in the VA 
system.

      One agency reported a backlog of over $100,000 in 
payments.

      The backlog was highest for TriWest and relatively even 
between the VA and Optum.

      Claims are paid randomly. One agency reported that August 
claims were paid for one client, but June claims were still 
outstanding.

Problems Obtaining Referrals/Prior Authorizations

      The prior authorization process between the VA and its 
TPAs appears dysfunctional.

      Agencies receive referrals from the VA, but have 
difficulty obtaining authorizations from Optum. Agencies provide care 
yet wait months for authorizations, which delays billing.

      Those agencies that have received authorizations report 
that documents do not sync with referrals. Some authorizations are for 
60-day episode periods, while the VA referrals are for a specific 
number of visits. It's unclear to agencies what they are required to 
track.

Rate cuts

      On October 1, provider payment rates for VA home care 
services paid for by Optum were decreased significantly with no advance 
notice.

      Rates for veterans referred by the White River Junction 
VT VA Medical Center dropped between 60 percent and 40 percent 
depending on the service.

      Rates for veterans referred by the Manchester, NH VA 
Medical Center dropped between 41 percent and 6 percent depending on 
the service.

      The rates for homemakers, who assist veterans with 
cooking, cleaning, laundry and groceries are now at $4.24 per 15 
minutes for Manchester patients and $4.23 for Vermont patients. These 
rates will not cover wages, insurance, taxes, supervision and mileage 
for these employees.

      For some agencies, the rate cuts will reduce their annual 
reimbursement for VA services by 50 percent.

      Some agencies plan to leave the VA provider network 
because of the rate cuts

Lack of Resg--onsiveness from the VA and TPAs

      Home health agencies report that communications between 
the VA, TriWest and Optum and its providers in the Community Care 
program is appalling.

      Agencies have difficulty reaching anyone who will speak 
to them, never mind resolve problems. One agency has been attempting to 
obtain an authorization for a referred client for over two years.

      It is not unusual to spend 4 to S hours on hold. Voice 
mail messages are seldom returned.

      Agencies have heard from some VA case managers that the 
recent rate cuts will be reversed. Unfortunately, the lack of official 
communications, either from the VA or Optum, creates an atmosphere of 
uncertainty.

    New Hampshire's home health and hospice agencies are proud to serve 
our country's veterans. Many hospice programs have implemented the ``We 
Honor Veterans'' program for those service men and women approaching 
end of life. However, the administrative burden and financial losses 
associated with the Community Care Program will lead to a serious 
decline in access to care for veterans in New Hampshire. When a home 
care agency leaves the provider network, it is unlikely that another 
agency will accept VA clients.
    I ask the Committee to urge the VA to work with its TPAs and 
provider network to resolve prior authorization delays, develop a 
reasonable fee structure, and restore trust with home health and 
hospice providers.

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