VA Access and Tribal Health Program Reimbursement Agreements

1. VA Access and Tribal Health Program Reimbursement Agreements Northwest Portland Area Indian Health Board Quarterly Meeting June 25, 2014

2. VA Access Audit • Nationally, audit covered 731 separate points of access • All medical centers, CBOCs serving at least 10,000 Veterans and sampling of smaller clinics were visited by audit teams • Over 3,700 administrative and clinical staff members involved in the scheduling process were interviewed • In VISN 20, the following sites were included in the audit • All 8 parent facilities (Anchorage, Seattle, Portland, Roseburg, White City, Boise, Spokane and Walla Walla) • Other clinics and CBOCs in Portland, Vancouver, American Lake, Eugene, Mount Vernon, Bremerton, Bellevue, Lake City, Port Angeles, Chehalis, Warrenton, Federal Way, West Linn, The Dalles, Yakima, Richland, Wenatchee, Boardman, Newport, Salem, Bend, Libby, LaGrande, Caldwell, Mountain Home, Brookings

3. System-Wide Findings • A complicated scheduling process resulted in confusion among scheduling clerks and front-line supervisors in a number of locations • A 14 day wait-time performance target for new appointments was inconsistently applied and not attainable due to growing demand for services and lack of planning for resource requirements • Overall, 13% of scheduling staff indicated they received instruction to enter a date different than what the Veteran had requested • 8% of scheduling staff indicated they used alternatives to the official Electronic Wait List (EWL)

4. Actions Taken by the Veterans Health Administration (VHA) • Revise, enhance and deploy Scheduling Training and overhaul the scheduling directive • Roll out near-term changes to the legacy scheduling system and acquire long-term scheduling software solutions • Implement a site inspection process • Removed the 14 day performance goal from employee performance plans and will reassess and establish new timeliness goals • Establish a new patient satisfaction measurement program • Post regular updates to access data • Senior Executive performance awards have been suspended for FY14 • Rolled out the “Accelerating Access to Care initiative”

5. Accelerating Access to Care Initiative - Goals • Increase timely access to care for Veterans patients • Decrease the number of Veterans patients on the EWL and waiting greater than 30 days for their care • Standardize the process and tools for ongoing monitoring and access management at VA facilities

6. Accelerating Access to Care Initiative - Implementation • Systematically reviewing clinic capacity to maximize ability to provide Veterans timely appointments • Identifying the resources required to provide timely care • Where VA cannot increase capacity, VA is increasing the use of care in the community through the non-VA care program (FEE) • Each facility is reaching out to Veterans to coordinate the acceleration of their care

7. Further Information Full access audit reports, twice monthly access updates, FAQs and other information are available on VA’s website: www.va.gov

8. Improving Access for American Indian and Alaska Native Veterans through Reimbursement Agreements • Eligible AI/AN Veterans can choose to receive their health care from the Tribal Health Program (THP) facility and/or VA Medical Center (VAMC). No pre-authorization by VA will be required for direct care services provided to eligible AI/AN Veterans if care is received at the THP facility • Reimbursement agreements with Tribal Health Programs focus on increasing coordination, collaboration, and resource-sharing for eligible American Indian and Alaska Native Veterans • The agreements promote quality health care through collaborative relationships and agreements 8

9. Direct Care Services • Direct Care Services are defined as any health service that is provided directly by THP. This does not include Contract Health Services, unless those services are provided within the walls of the THP facility. • VA will not reimburse for any services that are excluded from the Medical Benefits package or for which the eligible AI/AN Veteran does not meet qualifying criteria.

10. Benefits • Medical Benefits Package – VA will reimburse for direct care services provided under the Medical Benefits package available to eligible Veterans under 38 CFR § 17.38. • Pharmacy Options – THP health care facilities will be reimbursed when providing a 30-day supply of outpatient medications to eligible AI/AN Veterans. After the initial 30-day supply, eligible AI/AN Veterans may obtain prescriptions using the VA Consolidated Mail Outpatient Pharmacy (CMOP) for routine, long-term outpatient medication. • No Copayment – Pursuant to section 405(c) of the Indian Health Care Improvement Act (IHCIA), VA copayments do not apply to direct care services provided by the THP facility to eligible AI/AN Veterans under local reimbursement agreements. • Third Party Billing – Pursuant to section 405(c) of IHCIA, THP health care facilities will bill all third party payers, as permissible by law, prior to billing VA.

11. Payment Methodologies and Fees • Inpatient hospital services are based on Medicare Inpatient Prospective Patient System (IPPS). • Outpatient services will be based on the IHS All Inclusive Rate published in the Federal Register. • Critical Access Hospitals will be reimbursed at the established rate as determined by Medicare. • Ambulatory Surgical Services will be reimbursed at Medicare rates. • Administrative fees will be applied to the following claims: • Outpatient claims with the All Inclusive Rate will have a $15 fee per claim for the first two years • Paper claims will also incur a $15 fee for the duration of agreements

12. Basic THP Process for Establishing Agreements • Using the agreement template, the VAMC, THP, and Contracting Officer work together to complete the draft reimbursement agreement. • The national template shall always be used. • Concurrently, the THP works to satisfy local implementation criteria. • Once the draft is complete, it will be reviewed by VA’s Chief Business Office, Network Contracting Office and Regional Counsel, respectively. • After final signatures, reimbursement for direct care can commence.

13. Questions Regarding Reimbursement Agreements • Jodie Waters, VISN 20 Planner, Josephine.Waters@va.gov, 360-567-4684 • Terry Bentley, Tribal Government Relations Specialist, Western Region, Terry.Bentley@va.gov, 541-440-1271 • VHA Chief Business Office for Purchased Care, tribal.agreements@va.gov