# Presentation: 504403

## The U.S. Department of Veterans Affairs Fee/Non-VA Purchased Care Program

- Les Niemiec
-  VHA National Fee Program Manager
- Wayne A. Valey
- Chief, Communication and Training Division
- National Fee Program Office
- Prepared for the VA Treasury Meeting
- Austin, Texas      November 5-6, 2008

## Agenda

**Overview of Non-VA Purchased Care**

**Introduction**

**National Fee Program Office and Stakeholders**

**Execution**

**Strategy and Future State**

## Organizational Alignment

**National Fee Program Office**

**Contracted Purchased Care**

**Chief Business Office (16)**

**Deputy Chief Business Officer (CBO)**
**for Purchased Care**

**Director, Purchased Care Programs**

## How VA Provides Care to Veterans

**VA Care**
- Hospital-based
- CBOC
- Home Health

**Non-VA Care**
- Partnerships with Federal Agencies
-    DOD Military Treatment Facilities
- Partnerships with University Medical Teaching Affiliates
- Purchasing Care through Community
- Contracts
- Agreements
- Fee Basis

## Agenda

**Overview of Non-VA Purchased Care**

**Introduction**

**National Fee Program Office and Stakeholders**

**Execution**

**Strategy and Future State**

##  Fee Legislative Authorities

| 38 U.S.C 1703 | Obtaining Non-VA inpatient and outpatient medical services on a preauthorized basis by contract or individual authorization |
| --- | --- |
| 38 U.S.C 1725 | Reimbursement for emergency treatment of Non-service connected conditions in a Non-VA facility without prior authorization |
| 38 U.S.C 1728 | Reimbursement for emergency treatment of service-connected or related conditions in a Non-VA facility without prior authorization |
| 38 USC 8153 | Sharing Health Care Resources with Non-DoD health care providers, or other entities |

## Fee Program @ a Glance

- $4 billion/year program and growing
- 800,000 enrolled veterans in FY08
- 130 processing sites
- 2,000 VHA facility level staff
- IT support

- Expanded veteran benefits
- Increased legislation
- Increased diagnostic and treatment measures
- Resulting increase in amount of non-VA care
- EDI/FPPS computer system not HIPPA compliant and delays claims processing

## Reasons VHA Purchases Care from Non-VA Sources

**Ensure complete continuum of quality care when VA does not have internal resources available**
- Unable to access VA health care facilities
- Demand exceeds VA health care facility capacity
- Need for diagnostic support services for VA clinicians
- Need for scarce specialty resources (e.g., obstetrics, hyperbaric, burn care, oncology) and/or when VA resources are not available due to constraints (e.g. staffing, space)
- Satisfying patient wait-time requirements
- Ensure cost-effectiveness for VA (whereby outside procurement vs. maintaining and operating like services in VA facilities and/or  infrequent use is more appropriate)

## What Purchased Care is and is Not

| Purchased Care is | Purchased Care is Not |
| --- | --- |
| Supplement to VA health care | Substitute or replacement for VA health care |
| Secondary care when service is not available within the VA
- Limitations to extend care may be authorized | Primary care |
| Health care delivery system
- Requires matching of claims to individual authorizations for care | Insurance or a health plan
- No standard set of benefits |
| Flexible, can adapt Medicare payment rules for certain types of claims | Medicare or TRICARE |

**Augmentation of in-house capabilities and capacity**

## ExamplesNon-VA Provided Fee Care

| Fee Medical | State Veteran Nursing Homes with Free Drug Program |
| --- | --- |
| Fee Dental | State Veterans Domiciliaries |
| Contract Hospital [inpatient] | State Veterans Hospitals |
| Unauthorized Outpatient | State Veterans Adult Daycare |
| Millennium  Bill Emergent Care Dialysis | Contract Nursing Homes |
| Radiation Therapy |  |
| Fee Pharmacy/Prescription | Contract Adult Day Health Care |
| Comp and Pension | Respite Care |
| Organ Transplants | Homemaker/home Health Aide |
| Fee Travel/Fee Ambulance | Home Care [skilled, IV therapy, wound care, etc.] |
| Infertility and Reproduction/Fee Obstetrics | Hospice [home and inpatient] |
| Chiropractic | Appeals [Clinical, reconsiderations and BVA] |

**Types of programs supported vary from station to station**

**Notes:**
In several instances, funding and control is shared with other VHA program managers.  

Primary examples include:
> Prosthetics
> The State Home Program
> Out of System Payments (as made by Accounting)

Patient workloads and expenditures related to the above programs are not included in the data reflected in today’s presentation. The data reflected represents in-system payments captured though the VistA Fee system.

## Workload and Expense TrendsContinue to Rise

*Based on in-system payments; data does not include expenses for Prosthetics, State Homes or Out-of-System Payments*

- Reasons for Fee Program Growth:
- (1)  Emergence of the VISNs and the increased coverage to veterans via 870+ CBOCs
- (2)  Expansion of Benefits (for example, Medical Benefits Package (e.g., OB); Mill Bill; Community Care and Mental Health
- (3)  Increases in Legislation and Benefits
- (4)  Increased Diagnostic and Treatment Measures
- (5)  Efforts to Reduce Wait Times

**Notes:**
The Fee program has shown workload and expenditure increases each year.  Primary reasons include:
(1)  Emergence of the VISNs and the increased coverage to veterans via 870+ CBOCs.
(2)  Expansion of Benefits (for example, Medical Benefits Package (e.g., OB); Mill Bill; Community Care and Mental Health.
(3)  Increases in Legislation and Benefits.
(4)  Increased Diagnostic and Treatment Measures.
(5)  Efforts to Reduce Wait Times.

## Disbursed Amounts and Unique Patients by Fiscal Year and Stoplight FPOV Group - Graph

**Access to Care**
**Standards**

**CBO Emphasis**

**Mill Bill**
**2001**

**VistA Fee**
**Workload**
**Credit Memo**

**Disbursed Amounts and Unique Patients by Fiscal Year and Stoplight FPOV Group - Graph**

- Data displayed on the graph show the distribution of disbursements across FPOV groups by fiscal year fiscal year as compared to unique patients,
- Unique patients on this graph and table represent total unique patients by year.  Patients having services provided in multiple years will be counted once for each fiscal year.  Unique patients are displayed without regard to FPOV groups.
- Disbursed amount is based on those claims process through Central Fee and paid through FMS only.

## FY08 Fee Expenditures by Major Program Element

- Total: $3,029,213,856
- Other = Fee Dental $71M, Comp and Pen Exams $11M and Fee Pharmacy .5M

**Notes:**
Preauthorized Opt/Ancillary:                     1,072,369,353     (35%)
Preauthorized Inpt/Ancillary:                        676,883,920     (22%)
Community Nursing Home:                         $412,107,850    (14%)
Home Health Services:                                   360,728,820    (12%)
Mill Bill:                                                            275,063,475      (9%)
Unauthorized                                                 149, 629,344       (5%)
Other *:                                                             82, 431,095       (3%)
                                                                         -------------------
					Total:	     $3,029,213,856    (100%)

* Costs associated to other: primarily Fee Dental ($71m); Comp and Pen Exams ($11m); and Fee Pharmacy (.5m)

## Agenda

**Overview of Non-VA Purchased Care**

**Introduction**

**National Fee Program Office and Stakeholders**

**Execution**

**Strategy and Future State**

## Composition of VHA’s National Fee Program Office

-     The National Fee Program Office (NFPO) is a VA Central Office activity aligned under the Chief Business Office.  It consists of:
- VHA’s National Fee Program Manager
- Policy and Program Division
- Communication and Training Division
- Fee Consulting for VHA and Field Operations
- Fee Site Assistance Support
- Defining Business Requirements for Information Technology systems Needed to Support Fee Programs

***Fee 101***

## Internal VHA Medical Stakeholders

**VHA SERVICE SITES (1692)**
- VHA Hospitals (155)
- VA Nursing Homes (135)
- Residential Rehabilitation Treatment Programs (45)
- Outpatient Clinic Totals (1357)
- Hospital Based Outpatient Clinics (158)
- Independent Outpatient Clinics (4)
- Mobile Outpatient Clinics (6)
- Community Based Outpatient Clinics (872)
- VET Center (209)
- Home-care programs (108)

***Fee 101***

## THE FEE ARENA AT THE VAMC/COJ LEVEL

## Stakeholders

**  ****Examples of VA and Non-VA Stakeholders Involved in VHA’s Fee Programs**

- Revenue

- HEC

- BVA/COVA

- DSS/VSSC

- VA Regional Offices

- Program Managers from other Federal Agencies
- (Treasury, DoD, TRICARE, etc.)

- VA Financial Service Center
- and Central Fee   (Austin)

- Non-VA Care
- Advisory Committee

- FMS

- OI&T/Systems
-  Development

**National Fee Program Office**

- Fee Basis at the VAMC/COJ Level

- Parent VAMC: Management, Clinical Services
- (Medicine, Surgery, Mental Health, Ambulatory
-  Care, Long Term Care, CBOC’s) and Support
-  Services (Fiscal, A&MMS, IRMS, HAS,
- Quality Management, Risk Management, etc.)

- VISNs (21)

- VISN Fee Offices

- Other VAMCs (155)

- CBOCs (900+)

- Oversight: Internal, CBI,
- Joint Commission, GAO,
- IG (Medicare, Medicaid,
- VA), State Boards of Health

- Patients

- Family Members

- Veteran Service
- Organizations (DAV,
- American Legion,
- PVA, VFW, etc.)

- Collection
- Agencies

- Attorney’s: Federal,
- State and Private

- Unions

- Veteran Community

- Local
- Community

- State and Local
- Representatives

- Congressional Staff
- Inquiries

- Providers of Non-VA
- Medical Services
- (Clinical, Administrative,
- and Payment)

- Media

- VHA National
- Program Mangers

**Notes:**
There are a wide range of internal VA and external Non-VA stakeholders that have broad and diverse interests in the VHA Fee program.
Understanding their needs is a key factor in developing programs and policies to support VA missions.
Also important as we develop customer service initiatives.

## Agenda

**Overview of Non-VA Purchased Care**

**Introduction**

**National Fee Program Office**

**Execution**

**Strategy and Future State**

## Fee Claims Pricing Schedules

| 38 CFR | Regulates hospital and professional medical care claims pricing |
| --- | --- |
| 17.55 | Hospital inpatient use of facility care
 CMS Acute Care Inpatient Prospective Payment System (IPPS)
 Acute Care IPPS Exempt
 Per Diem based on extent of authorization |
| 17.56 | Physician and Outpatient use of facility care
 CMS Resource Based Relative |
| 17.1005 | “Mill Bill” payer of last resort pricing |

## Fee Program Proposed Legislation and Regulation

- Expand Fee Emergency Treatment Coverage
- Pay past point of stabilization when VA facilities are unavailable
- Broaden authorization for referral to Non-VA facility
- Include needed Non-VA hospital care to complete course of treatment for any enrolled veteran (now limited only for outpatient services)

- Adopting Medicare Payment Schedules
- Ambulance
- Ambulatory Surgical Center
- Anesthesia
- Dialysis
- Laboratory
- Home Health
- Hospital Outpatient

## Process Improvement Activities

| Claims Processing Timeliness
Monitoring at the local facility, VISN and national level
 First report May 2007 - 79% processed within 30 days
 September 2008 - 90% processed within 30 days
 Working towards automated reporting
 |
| --- |
| Non-VA Care Waiting Time Pilot
 Assessment of overall management of pre-authorized
 Focus on VA driven metrics to meet access standards
 Assessment includes timeliness of VA authorizations and claims processing
 4 facilities at present; intended to redesign best business practices
 |
| COTS Implementation
 Enterprise deployment of automated claims processing system
 2 phases to allow interim benefits while long-term solution is managed
 Dramatically improves EDI capability
 Deployed in 7 VISNs |

## Process Improvement Activities

| External Stakeholders Focus Group
 Understand community needs
 Develop stronger partnerships to improve veteran care |
| --- |
| Business Process Redesign
 Full assessment of changes necessary to improve entire process
 Initial work 2008; final 2009 |
| Enhancement of Metrics
Data analytics to allow full understanding of breadth of program needs, issues, concerns
Outcomes based to assure best approach for full continuum of care for veterans |

***Improving clinical continuity and support***
***for accurate and timely diagnosis and treatment***

## Other Initiatives

- The Recovery Audit for Inpatient Hospital Facility Payments
- Independent auditor assesses VA pricing for erroneous payments
- Claims
- Medical documentation
- Coding issues
- Per Diem pricing
- Notifications in writing with opportunity to dispute
- VA Medical facilities receive refunds
- Over $50M established since audit began

- Fee Claims Re-pricing
- VA discounted pricing via agent contract with access to network provider discounts
- Regulated business practice for claims paid in accordance with:
- Title 38 CFR 17.55
- 	Inpatient hospital facility
- Title 38 CFR 17.56      Professional and outpatient facility

## Other Initiatives

- Fee Purchase Card Program
- Alternate way to issue Fee care payment to providers through Citibank government purchase card
- Providers must register to participate
- Participating providers are required to absorb transaction fees
- Fee payments made through this program are not subject to Federal Prompt Payment Act
- Money management standards-potential to deliver payment expeditiously

## Agenda

**Overview of Non-VA Purchased Care**

**Introduction**

**National Fee Program Office and Stakeholders**

**Execution**

**Strategy and Future State**

## VHA Strategic Plan for Fee

- Strategic Plan
- Subject Matter Experts from VACO Program Offices and the VISNs
- 6 major strategic goals
- Customer Service
- Education
- Enhanced Healthcare
- Information Technology
- Legislation and Policy and
- Resource/Financial Management
- 40 objectives, 133 tasks
- Targeted completion dates, based on 1, 3  and 5-year timelines

- Possible Constraints
- Time
- Resources – staff competency /turnover and funding allocations
- IT competition for priorities and funding
- Legislative and regulatory timelines
- Policy change timelines

## Looking Towards the Future

- VHA Fee Programs and the U.S. Treasury have shared interests
- Important that we identify central issues that affect the successful implementation of business processes that help to achieve goals to provide support to our nation’s veterans
- Important to proactively work together to assure that our shared interests are met

## Items of Current Interest (continued)

- Establishing avenues/forums that promote an
-      understanding of each Agency’s roles and needs
- (2) Establishing a clearer method of identifying and
-       tracking progress on initiatives for shared
-        interests.
- Identifying appropriate hardware and software
-       systems that meet business needs

## Items of Current Interest (continued)

- Accommodating changes in VA’s Financial
-       Management Systems (FMS), such as IPAC
-       and claims adjustment explanations
- (5) Educating non-VA providers/vendors
- (6) Expanded use of Electronic Fund Transfers
- Identifying ways to reduce the number of
-       undeliverable checks

## 

           Information Resources

-            **Information Resources**

## Information Resources

- Visit http://www.va.gov/hac/HERO, email vhahacprojecthero@va.gov, and/or contact any of the Project HERO team members listed below

| Name and Title | Address | Phone | E-mail |
| --- | --- | --- | --- |
| Sam Eden
Director, Non-VA Purchased Care Programs | VHA Chief Business Office - Field Office
3773 Cherry Creek North Drive
Denver, CO  80209 | 303-370-5089 | sam.eden@va.gov  |
| National Fee Program Office |  |  |  |
| Les Niemiec
National Fee Program Manager | VHA Chief Business Office - Field Office
3773 Cherry Creek North Drive
Denver, CO  80209 | 720-889-2349 | Leslie.niemiec2@va.gov
 |
| Tom Wayburn
Supervisory Program Specialist | VHA Chief Business Office – Field Office
3773 Cherry Creek North Drive
Denver, CO  80209 | 303-370-7757 | Thomas.wayburn@va.gov   |
| Joe Enderle
Manager, Non-VA (Fee) Field Assistance Unit | VHA Chief Business Office – Field Office
17273 SR 104
Chilicothe, OH 45601 | 740-773-1141 x6220 | Joseph.enderle@va.gov
 |
| Wayne Valey
Chief, Communication and Training Division | VHA Chief Business Office – Field Office
3773 Cherry Creek North Drive
Denver, CO  80209
 | 303-398-5908 | Wayne.valey@va.gov   |
| Karen Hudgins
COTS Deployment Manager | VHA Chief Business Office – Field Office
3773 Cherry Creek North Drive
Denver, CO  80209 | 727-894-4105 | Karen.hudgins@va.gov |
| Contracted Purchased Care |  |  |  |
| Carol Chipman
Program Manager, Project HERO, VHA CBO | VHA Chief Business Office - Field Office
3773 Cherry Creek North Drive
Denver, CO  80209 | 303-331-7522 | carol.chipman@va.gov  |
| Greg Eslinger
Assistant Program Manager, Project HERO | VHA Chief Business Office - Field Office
3773 Cherry Creek North Drive
Denver, CO  80209 | 303-619-6023 | greg.eslinger@va.gov |

**Notes:**
If you have any questions, don’t hesitate to contact us.

## Questions and Discussion

**Notes:**
Thank you.