Community Care specifically §17.1535

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RHE
Posts: 1
Joined: 2019-12-30 09:24:18

Community Care specifically §17.1535

Post by RHE »

I am new to this board and I hope I can gain some support or feedback regarding Community Care (Mission Act). Below is a copy of my letter sent to the Senate Committee on Veterans Affairs. Since this letter was sent, I have discovered instances of where the treating facilities have misplaced the Tricare letter and sent the bill directly to the VET as well.




This issue involves how treatment though Community Care is placing many Vets in collections all over simple misunderstandings stemming from §17.1535. How this is happening:

Go to CBOC get referral.

Get Community Care approval: VA will only pay for an episode of care for hospital care or medical services authorized by VA. The eligible entity or provider must contact VA to receive authorization prior to providing any hospital care or medical services the eligible non-VA entity or provider believes are necessary that are not identified in the authorization VA submits to the eligible entity or provider. §17.1535 Payment rates and methodologies.

Go to appointments.

Months later get letter from a Collection Agency demanding payment for services.
Spend days contacting debt collector, community care, patient advocate, Community Care collections (which assists in these matters) and even my Senator (Hoeven). Find out the Doctor, Nurse or Administrator did not seek approval for treatment under the referral.

Personally I deny all liability on grounds the grounds that I did not give the Doctor, Nurse or Administrator permission to act outside the scope of VA authorization and they failed to follow the referral. Therefore, the clinic, nurse or administrator should be held liable for any expenses incurred.
It is easy to complain; but, I would like to propose a solution to this issue that all may agree to. I see three possible approaches to this issue. The first of which is legislate or regulate; the second is adjudicate; the last is training.

I personally do not think that more regulations or legislation is necessary in this matter since it boils down to a simple application or SAR. In other words, I believe the standing regulations are sufficient. See §17.1535 Payment rates and methodologies.

As far as adjudication goes, it has always been my opinion that courts should be used only as a last resource. Unfortunately, unless I can resolve this matter (which is looking good now) it remains an option.

The training approach I believe is the simplest of the three and may be agreeable to all. The problem seems to lie with nurse’s not timely filing SARs; or, where a SAR was sent by the nurse but the appointment happens before the SAR’s approval. A couple of points to consider:

- Community Care is somewhat understaffed; but, is being addressed and to this point has done an excellent job in ND, given staff. This is somewhat slowing the process of the SAR approval now.

- Hospitals want to be paid. Quite frankly, most business hate collections as much as the debtor; It cost both of them money.

- VA cost of managing complaints, follow-ups, and case management has to be rising given the number of Vets affected. Not to mention the level of frustration for the Veteran.

I believe the Dept. of Veteran Affairs should contact the treating facilities and educate both admin and nurses on how to handle a veteran. I believe this could be done in a three to five minute video explaining the following: Understanding the authorization, what is a SAR and how to file one, and last what do when a SAR was sent; but, the appointment took place before approval.

I believe this would substantially lower the number of occurrences, and Veterans frustration with Community Care.

Sincerely,
Rodney H Evoniuk




§17.1535 Payment rates and methodologies.
Section.
. . .
(2) For hospital care or medical services furnished for a service-connected disability, as that term is defined at §3.1(k) of this chapter, or pursuant to 38 U.S.C. 1710(e), 1720D, or 1720E, VA is solely responsible for paying the eligible entity or provider for such hospital care or medical services as are authorized under §§17.1500 through 17.1540 and furnished to an eligible veteran.
(c) Authorized care. VA will only pay for an episode of care for hospital care or medical services authorized by VA. The eligible entity or provider must contact VA to receive authorization prior to providing any hospital care or medical services the eligible non-VA entity or provider believes are necessary that are not identified in the authorization VA submits to the eligible entity or provider. VA will only pay for the hospital care or medical services that are furnished by an eligible entity or provider. There must be an actual encounter with a health care provider, who is either an employee of an entity in an agreement with VA or who is furnishing care through an agreement the health care provider has entered into with VA, and such encounter must occur after an election is made by an eligible veteran.
(Authority: Secs. 101, 105, Pub. L. 113-146, 128 Stat. 1754)
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