Payment for VA Services Dale Gaudio, RHIA, CCS-P Washington DC VAMC December 20, 2013

Unscheduled Services Medical Records must accompany all emergency or unscheduled services. – All Physician Notes – H&P – Discharge Summary – Operation/Procedure reports No other information is required. Nursing notes and orders are counterproductive.

Follow up Claims sent without records will be rejected – There is a 30 day window for follow up on most claims. – If not received in 30 days, permanent denial can be the result. Ideally claims and records should come together

Electronic Claim Submissions We encourage EDI claims for pre-authorized services Our process requires us to scan claims and have an OCR system read them. EDI eliminates several steps and speeds up the process. System only stores data for 45 days – Important to monitor the Remittance advice

Pre-authorized claims Records should be submitted within 14 days of the date of service We may ask you to submit them immediately so that we can further authorize other care. All sites have a case manager

Payment Issues All Payments are governed by 38 CFR – These may not be completely in line with state law for outpatient cases. – Do not expect that the amount reimbursed will be exactly what is received from Medicare – Ensure that ALL claims with a 278 revenue code have a CPT code listed. An unlisted code is OK. – System cannot pay lines without a code

Reminders VA does audit claims for services against documentation VA has an IG that does do investigations into inappropriate billing practices VA is a Federal Health Care Program