Veterans Access, Choice and Accountability Act of 2014 (VACAA) The Choice Program and the Choice Card ***UPDATED*** April 24, 2015 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:

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 1-800 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

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.

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 113-146 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.

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

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.

Veteran Choice Program – 30+ Days (continued) Veteran is made aware that they are eligible to use Choice Program and provided the 1-800 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

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

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 1-800 number and adds the Veteran to the VCL for that specialty.

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

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.

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”.

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

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 113-146 (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). 

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

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

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)

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): http://vaww.va.gov/choice/ VA VACAA web site (Internet – external): http://www.va.gov/opa/choiceact/ Access Advisor e-newsletter Facility leadership Choice Champions

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