0. Veterans Access, Choice and Accountability Act of 2014 (VACAA) The Choice Program and the Choice Card ***UPDATED*** April 24, Special Thanks to Robert H. Taylor- Chief Business Officer and CHOICE Program Subject Matter Expert
Good morning / Afternoon, I’m NAME/TITLE/ORG– I’ll be moderating today’s call. Before we get started with our presentation, I’d like to cover some housekeeping items:
First, we want to make sure everyone on this call has a good understanding of what we WILL and what we WON’T be covering over the next hour.
We’re going to be solely focused on the Choice Program and the Choice Card ONLY
Our singular audience focus is the VHA workforce -- to ensure you have the information and resources you need to help VA successfully stand up and roll out this new program
More pertinent for this call: The call will be conducted in lecture mode, which means that only presenters will be heard most of this call
To that point, questions and answers will be held until the end of the call to ensure we cover all basic information found in the slides – which should address 85% of questions/concerns
This calls will be recorded, so we can post it to a website where others who can’t make today’s call can access it later
Finally, a reminder that the call is offered by both VANTS AND Adobe Connect – pick one of those two options and make sure your settings are such that you can hear us without any echo or feedback.
With no further ado, let’s get on with the presentation by introducing our speakers:

1. VHA Employee Communication and Education Strategy and Implementation Timeline
Four-Pronged Employee Communication and Education Strategy:
Push known info NOW
Deploy Communication and Education Toolkits
Use PA channels to undergird rollout / sustain knowledge, awareness and support
Business implementation: Facilities prepare for and assist Veterans during roll-out
Nov. 5
In recognizing importance of our workforce as a critical audience, this effort is soled focused on VHA employees, but in full coordination with other groups that are charged with addressing Veteran and external communications about VCP
VHA Employee Communication and Education Strategy:
Push known info NOW – fact sheets, FAQs, website, prep steps, etc. – this presentation is a key element in that strategy
Communication and education toolkits: Two main audiences:
Facility SMEs and Choice Champions
All other Veteran-facing staffs
Toolkits will include needed resources – most staff will just need high-level info, background and need to know where to point interested or concerned Veterans. Facility leaders, patient advocates, Choice Champions will need actionable knowledge to best assist Veterans – won’t just hand off Veterans to TPA number. At least two MyVEHU sessions set, and we’re pitching broadcast/video solution as well, to demo Veteran interactions and best practices
Undergird rollout / sustain knowledge, awareness and support via PA channels – Commsite, VA website, Dr. Clancy’s weekly messages, Access Advisor, guidance and messages to PAOs, etc.
Business Implementation Strategy: prepare sites to support roll out, scrub databases, establish Choice Champions, etc. 1 2 4 3
October
November
December

2. Choice Card Production / Distribution
TPA to provide :
Card distribution, call center, Veteran counseling, provider management, appointment management, reporting and billing.
Instruction letter for how to use card will accompany card
Phased distribution
Card design approved and ready for production.
Phased distribution: Nov 4-6: Veterans who live more than 40 miles from a VA facility, Nov 17-30: Veterans waiting for an appointment more than 30 days from their preferred date, or the date determined medically necessary by their physician, Dec 1-Jan 31: All remaining Veterans enrolled as of Aug 1, 2014.

3. Veterans Choice Program – 40+ Miles
TPA is provided list of eligible Veterans that reside more than 40 miles from VA facility
Distance is calculated by address in VistA
This list is updated monthly
Veterans is notified of their eligibility through mailings
Veteran can choose to contact TPA and coordinate ALL care
Care is pre-authorized by VA based on eligibility and clinical criteria is determined by TPA using InterQual standards
Care Provided is paid by CBO with funding authorized in PL
Ex: Vet needs hip replacement, all related care, i.e. workup, surgery and rehab considered episode of care. Approval for episode of care is only authorized for 60 days and must be renewed
Notes for Ex:  A Veteran is eligible for choice because he/she is a 40 miler.  The Veteran needs a hip replacement.  When the TPA approves/provides the appointment for the procedure the appointment authority is good for 60 days.  So all pre surgical workup, the hip replacement surgery, and rehabilitation would be paid by VA through the TPA as long as all the work is accomplished within 60 days.  Any needs related to the hip replacement not completed within 60 days would require the Veteran to contact the TPA again.

4. Veterans Choice Program – 40+ Miles (continued)
VA will own the Electronic Health Record (EHR) – even if the Veteran is never seen in a VA facility
Veteran is seen by Non-VA Choice Provider
Choice provider submits claim, Explanation of Benefits (EOB) (if applicable) and clinical documentation to TPA
TPA processes payment to Choice Provider
Payment is at PC3 contract rate, Medicare rate or other specific rates identified in regulation when Medicare rates do not exist
TPA submits claim, EOB and clinical document to Chief Business Office Purchased Care (CBOPC ) for payment
Claim is processed in Fee Basis Claim System (FBCS) by CBOPC staff
Clinical documentation is uploaded into CPRS by NVCC staff
Consolidated Patient Account Centers (CPAC) staff will determine VA copayment and bill Veteran appropriately
CPAC staff will reconcile OHI cost shares/co-pays

5. Veteran Choice Program – 30+ Days
Clock starts ticking based on “clinically indicated date” (CID)
If no clinically indicated date, patient preferred date is used
If we KNOW that community wait is longer than VA wait, we should inform the Veteran, who can then make an informed choice about care
VA will use Veteran Choice List (VCL) to identify those 30+ days – adding patient to the VCL is the authorization for care
Ex: If Veteran is offered an appointment and can’t be seen within 30 days of CID or preferred date, Veteran is offered Choice Program and can make a decision to keep the appointment or seek care through Choice Program
Notes for Ex:  If a Veteran has a need for three appointments such as Cardiology, Podiatry and GI.  The VA can provide the Cardiology and Podiatry appointments to the Veteran within 30 days of Clinically Indicated Date but cannot provide the GI appointment within 30 days of CID.  The Veteran would be given an appointment for the Cardiology and Podiatry requests at his/her local VA (these two appointments are not Choice eligible b/c they are w/i 30 days CID) and the Veteran would have a CHOICE of contacting the TPA for a GI appointment in the community or the Veteran can CHOOSE to have the GI appointment at his/her local VA.

6. Veteran Choice Program – 30+ Days (continued)
Veteran is made aware that they are eligible to use Choice Program and provided the number for the TPA
VCL list data is transmitted to TPA daily
Clinical information for the appointment is transmitted to TPA through portal
Veteran contacts TPA for information and/or use of Choice Program
If Veteran decides NOT to use Choice for this episode of care, the original provider’s consult and appointment will remain as scheduled.
If Veteran selects to use Choice Program
TPA gathers OHI information
TPA uses original providers consult or RTC Progress Note to determine what services are to be scheduled
TPA provides Veteran with list of approved Choice providers

7. Veteran Choice Program – 30+ Days (continued)
Veteran is seen by Choice Provider
Choice provider submits claim, Explanation of Benefits (EOB) (if applicable) and clinical documentation to TPA
TPA processes payment to Choice Provider, payment is at PC3 contract rate, Medicare rate or other specific rates identified in regulation when Medicare rates do not exist
TPA submits claim, EOB and clinical document to Chief Business Office Purchased Care (CBOPC) for payment
Claim is processed in FBCS by CBOPC staff
Clinical documentation is uploaded into CPRS by NVCC staff who complete consult
Consolidated Patient Account Centers (CPAC) staff will determine VA copayment and bill Veteran appropriately
CPAC will reconcile OHI cost shares/co-pays

8. VA Choice Process Flow – 30+ days
Providers (no change in current state)
Determines if traditional NVCC would typically be used.
If yes, continue with NVCC consult
If no, submit a specialty consult as one normally would.
MSAs
Determines if appointment > 30 days out from clinically indicated date and is patient eligible for Choice based on enrollment date (enrolled by August 1, 2014 or a Combat Veteran).
If yes, reads script to inform Veteran of Choice Program and provide number and adds the Veteran to the VCL for that specialty.

9. VA Choice Process Flow Overview – 30+ days
Non-VA Care Office
NVCC staff pulls yesterday’s VCL and EWL and ordering provider’s consult for each of those patients on the list (or RTC and last progress note for those patients that do not have a consult- established patients)
Provide copies of this information to the TPA
Please Note: You are not creating a non-VA care consult. The purpose of this action is to provide the TPA with necessary clinical information if the Veteran calls.
TPA
Receives phone call, explains program, makes appointment
Communicates back to Non-VA Care staff with appointment info

10. VA Choice Process Flow Overview – 30+ days
Non-VA Care Office
NVCC staff or MAS/HAS/Business Office Staff (recommend that this be NVCC staff ) cancels VA appointment, cancels consult if one exists (new patients) and enters comment “Veteran Selects VA Choice”
NVCC staff would create a clinical tracking record in FBCS
NVCC staff creates authorization in FBCS
Wait for claim and clinical documentation to come back.
NVCC would load a patient specific progress note and pull clinical documentation from TPA portal to upload.

11. Veterans Choice Progress Note
Care coordination information for Veterans Choice consults can be documented using the VETERANS CHOICE NOTE progress note title. This title is mapped to the VHA Enterprise Standard Title “NONVA PROGRESS NOTE”.

12. Third Party Administrator
Providers are either part of the TPA network or out of network with TPA but meet requirements of the Choice Act
TPA will provide list of approved providers to Veteran to choose
TPA will schedule Veterans community appointment OR send back to VA
TPA sends through portal appointment information to primary facility
NVCC office will enter into FBCS in preparation of receipt of claim
Responsible to provide clinical documentation to VA
If Veteran is Service Connected
TPA will contact CBO to obtain SC/NSC determination
If for NSC condition AND Veteran has insurance TPA will notify provider they must bill OHI first
Coordinates other health insurance (OHI) information with provider and responsible to provide Explanation of Benefit (EOB) to VA

13. General Matters
Identify stop codes that shouldn’t be Choice: Agent Orange, Burn Pit, etc.
Prescriptions written by Choice provider needs to be paid from money authorized through PL (same for Prosthetics)
Pharmacy and Prosthetics benefit: utilizing current in-house process (same as other non-VA medical care prescriptions)
Additional guidance will be provided
A determination still needs to be made on how the provider information will be captured in VistA for the Choice prescriptions
Care Coordination will be critical
A Viewer will be provided for “approved” staff to confirm Choice eligibility
Care Coordinator:  This would be an individual with a clinical background who would serve as an interface with the TPA to ensure Veterans receive their appointment and ensure the appropriate clinical documentation is returned to VA from the TPA.  The Care Coordinator would serve as a monitor to ensure appropriate documentation gets scanned into the Electronic Health Record and appropriate notices go to the VA physician who made the referral for care.  Many VAs currently have individuals such as these who work with community providers when referrals are made through NVCC (Non VA Care/Fee Basis Vouchers). 

14. Key Issues – Copayments and Secondary Payers
VA Copayments
Draft regulation eliminates VA copayment at time of service and allows it to be charged to the Veteran after care provided and coordination of benefits processed
Other Health Insurance (OHI) Cost Shares/Copayments/Deductibles
Requires Veterans with OHI to provide info to VA if selecting Choice Program
Declining to provide OHI results in loss of this benefit
OHI cost shares will be due by the Veteran to the provider or the OHI
VA does not have authority to interfere with health plan requirements
May shift up front costs to Veterans with OHI
VA can only pay up to the Medicare rate minus the cost of care provided
If the total of the cost of care plus the cost shares exceed the Medicare rate, Veteran may be left owing some portion of cost share
Care for service connection or those without OHI will not incur additional expense
Education will be critical in ensuring Veterans are not surprised

15. Total Charges to Veteran
Examples of Charges for Choice Care: Copayment Required – Veteran Seen for Specialty Appointment
Veteran is seen for a specialty appointment. The visit is $250 / Medicare Rate is $250 for care provided:
Total Cost to VA
Total Charges to Veteran
(includes VA copayment and insurance cost shares)
No OHI
$250
$50
OHI denies claim
$250**
$50**
OHI paid in full $0
$0* (offset by OHI payment)
OHI paid $220
$30
OHI - $250 of outpatient deductible applied to this claim; OHI paid nothing
OHI paid $220; met deductible; $30 cost-share; OHI payment to provider
$0 (offset by OHI payment)
OHI payment offsets the Veteran VA copayment and insurance cost share; adds to VA cost for lost collections in Traditional VA and NVC
**Reference business rules for evidence of denials management from TPP/OHI for TPA

16. Actions to take NOW to get ready for the Choice Program:
Educate facility “Choice Champions”
Educate clinical staff on “Clinically Indicated Date” (CID)
Standardize location of CID
Establish clinic identifiers
Identify 30+ days (none prior to 12/1/14)
Place any new identified 30+ day Veterans on VCL
Identify TPA liaison
Identify care coordinator
Validate Veterans’ addresses
Point your staffs to training and resources (next slide)

17. Additional Choice Program Training, Resources and Information:
Multiple training webinars offered the week of November 3 for Choice Champions
MyVEHU sessions Nov. 6 and Nov. 20 – Save the Date!
VA VACAA web site (Intranet – internal):
VA VACAA web site (Internet – external):
Access Advisor e-newsletter
Facility leadership
Choice Champions

18. The VACAA Intranet Page – Your “Hub” for Choice Program Information, Resources:
Job Aid Toolkits
Fact Sheets
FAQs
News Releases
More added regularly