Payment for VA Services

1. Payment for VA Services Dale Gaudio, RHIA, CCS-P Washington DC VAMC December 20, 2013

2. Unscheduled Services • Medical Records must accompany all emergency or unscheduled services. • All Physician Notes • H&P • Discharge Summary • Operation/Procedure reports • No other information is required. • Nursing notes and orders are counterproductive.

3. Follow up • Claims sent without records will be rejected • There is a 30 day window for follow up on most claims. • If not received in 30 days, permanent denial can be the result. • Ideally claims and records should come together

4. Electronic Claim Submissions • We encourage EDI claims for pre-authorized services • Our process requires us to scan claims and have an OCR system read them. • EDI eliminates several steps and speeds up the process. • System only stores data for 45 days • Important to monitor the Remittance advice

5. Pre-authorized claims • Records should be submitted within 14 days of the date of service • We may ask you to submit them immediately so that we can further authorize other care. • All sites have a case manager

6. Payment Issues • All Payments are governed by 38 CFR 17.56 • These may not be completely in line with state law for outpatient cases. • Do not expect that the amount reimbursed will be exactly what is received from Medicare • Ensure that ALL claims with a 278 revenue code have a CPT code listed. An unlisted code is OK. • System cannot pay lines without a code

7. Reminders • VA does audit claims for services against documentation • VA has an IG that does do investigations into inappropriate billing practices • VA is a Federal Health Care Program