VA's private-care initiative impeded by administrative issues

Administrative and reimbursement issues are hampering the Veterans Affairs Department's new initiative aimed at granting wider access to private care for vets unable to get treatment within the system, say some providers around the country who have tried working in the new program.

Allowing more veterans to seek private sector care was made possible by a $16 billion veterans-related measure signed by President Barack Obama in August. The legislation followed a series of reports that thousands of veterans were waiting months for care at VA facilities.

But as veterans have begun to receive information on how to access care outside VA facilities, providers located in some of the most rural regions of the U.S. say they've either declined to contract with the managed-care companies involved in the program or haven't been approached.

“No, (we don't have a contract) due to significant administrative requirements, low reimbursement and desire to contract directly with the VA rather than through a third-party contractor,” said Julie Burton, a spokeswoman for the Billings (Mont.) Clinic, an integrated health system that includes a 240-physician group practice, a 285-bed hospital, a network of rural clinics and a nursing home.

Representatives from numerous other hospitals including Froedtert & the Medical College of Wisconsin, Milwaukee; Backus Hospital, Norwich, Conn.; Windham Hospital, Willimantic, Conn.; Baker County (Fla.) Medical Services; and Baptist Health South Florida, Coral Gables, say they either haven't contracted or haven't been asked by either of the managed-care companies involved to do so.

The VA emergency funding law states that “rates negotiated shall not be more than the rates paid … under the Medicare program.” As a result, the VA pays Medicare rates to TriWest Healthcare Alliance or HealthNet Federal Services, the managed-care companies the department has contracted with to oversee the choice program.

But the companies reimburse at less than Medicare rates to ensure their profitability as well as to amass funds to pay doctors above Medicare rates in the instances where no other providers are available in certain areas.

“We are not connected to the negotiations they have with local providers, so we don't know what they are actually reimbursing,” a VA spokeswoman said.

So while low rates are turning some providers away from the program, those providers that have signed agreements say that administrative woes plaguing TriWest are giving them major headaches.

TriWest did not respond to numerous calls and e-mails seeking comment. HealthNet representatives declined to discuss any rollout challenges, but said that its hospital network for the program has nearly doubled in the past six months.

For its part, the “VA has been working to ensure a smooth implementation of the program and is continuously looking for opportunities to add more providers,” a VA spokesman said.

Kevin Kramer, CEO of Modoc Medical Center, Alturas, Calif., counters that “we're struggling to figure out how to bill and what people we should call about it.” His facility has seen three veterans thus far.

The VA, on Nov. 5, mailed 320,000 medical choice cards and usage instructions to veterans who reside more than 40 miles from any type of VA medical facility. Another 370,000 cards started going out around Thanksgiving to veterans who have waited longer than 30 days to see a doctor.

A choice card does not mean immediate access to the private sector. A veteran must get prior authorization from the VA and the provider must have a contract in place with either TriWest or HealthNet.

The cards have a contact number on them, “but we don't seem to be able to reach anyone who knows what they're talking about,” Kramer said.

Because of the communication issues, his hospital also has had trouble finding out if the three veterans have gotten the appropriate prior authorization. As a result, his hospital could ultimately end up absorbing their treatment costs, he said.

Ridgecrest (Calif.) Regional Hospital has found itself in a holding pattern. Even with a contract in place, it can't see any veterans until its providers are listed as covered in the choice program's provider database. It's been waiting weeks for TriWest to address the issue, according to CEO Jim Suver.

The nearest VA facility is three hours away, so veterans have been anxious to use the hospital, Suver said. While all new programs can stumble during implementation, he is surprised about the issues TriWest seems to be having getting the program off the ground.

“I thought it would be much smoother than this, especially considering the importance,” he said. “Veterans were led to believe that as soon as they got the card it would be a slam dunk and everything would be fine, but it hasn't gone that way.”

Copper Queen Community Hospital in Bisbee, Ariz., also has a contract in place, but has yet to see any veterans with choice cards walking through its doors. More vigorous outreach is needed to let veterans know about their options under the choice program, contends its CEO, James Dickson.

Follow Virgil Dickson on Twitter: @MHvdickson