Veteran: Non-VA Emergency Care Claims Inappropriately Denied and Rejected or General, Do You Know the Definition of a Veteran's Benefit?
Response to the VA Inspector General Report of 8/6/2019 --General, Do You Know the Definition of a Veteran's Benefit?
Update February 2020
Original August 2019
General do you know the definition of a veteran's benefit. Don't be embarrassed, nobody in the DVA doses either. There are volumes and volumes of examples but no definition. At the end of this post is the correct definition.
Original August 2019
General do you know the definition of a veteran's benefit. Don't be embarrassed, nobody in the DVA doses either. There are volumes and volumes of examples but no definition. At the end of this post is the correct definition.
The Law has statutes on eligibility and limitations. This report is about one statute and the VA concocting a regulation the VA used to deny benefits. This concoction is a source of millions of dollars denying benefits to veterans.
The VA contrived a regulation not compliant with the Law -- it's a lie. The OIG report exposes the consequences of the lie.
The poor staffers who wrote the report do not understand Title 38 principles and principals. The illustration Congress & Veterans & DVA & Provider is a mind map of the principles in 38 USC 1725 and their relationships. The report failed to determine first-order problems. The child says, mom where are the potatoes? The mom says there are not potatoes, the grocer did not have any. The grocer says, there are no potatoes, my distributor did not have any. The distributor says, there are no potatoes. The farmer did not have any. The farmer says there are no potatoes because it did not rain.The farmer not having potatoes is the first-order problem. Not raining is a different problem. The distributer is second order, the grocer is third order, the mom is fourth-order, the child is the problem reason. The report fails both to identify the reason and the first-order problem.
The section name for 38 U.S. Code 1725 is "Reimbursement for emergency treatment." I am bewildered that DVA regulations and rules authors did not read the first two statutes. A section name is a language convenience to represent a collection of statues on a particular topic. The section name is not a statue nor does it represent a constraint applied to the statues.
The term reimbursement is a well-defined business process. The Law says:
(a)General Authority.—
(1)Subject to subsections (c) and (d), the Secretary shall reimburse a veteran described in subsection (b) for the reasonable value of emergency treatment furnished the veteran in a non-Department facility.
(2)In any case in which reimbursement is authorized under subsection (a)(1), the Secretary, in the Secretary’s discretion, may, in lieu of reimbursing the veteran, make payment of the reasonable value of the furnished emergency treatment directly—
(A)to a hospital or other health care provider that furnished the treatment; or
(B)to the person or organization that paid for such treatment on behalf of the veteran.
The Law is very clear either reimburse-the-veteran or pay-the-provider. In both cases, an invoice must come from the veteran or from the provider. By Law, the DVA cannot reimburse the provider.
The Law statue "organization that paid for such treatment on behalf of the veteran" gives the veteran permission to submit a reimbursement invoice for the veteran's private health plan payment to the provider. 38 USC 1725 (c) (4) (D) prohibits the veteran from double-dipping on the medical expense payout, payment from private insurance and payment from the DVA. The regulation CFR 17.1005 (5) permits double-dipping.
Without reason or cause, the DVA created a regulation completely disjoint from the Law. And in doing so, DVA cost the wellness of thousands of veterans and perhaps even deaths.
A Fictitious Regulation
CFR 17.1005 (5) "VA will not reimburse a veteran under this section for any copayment, deductible, coinsurance, or similar payment that the veteran owes the third party or is obligated to pay under a health-plan contract.” A bayonet policy, stabbing veterans in the back by denying the Goodwill Grant.
Here is the Law:
The Law's statute 38 USC 1725 (c) (4) (D) states “The Secretary may
not reimburse a veteran under this section for any copayment or similar payment
that the veteran owes the third party or for which the veteran is responsible
under a health-plan contract."
What should have happened:
If the veteran is eligible and used a reasonable person's decision for adverse conditions had emergency room treatment at a non-VA facility, then the Law instructs the VA to pay-the-provider for the unpaid medical expenses. The Law instructs the provider to reconcile all other payments before invoicing the VA. VA Form 10-7078 is the invoice form providers submit that lists the unpaid medical expenses. Neither Title 38 nor Privacy Law grants the VA privilege to demand details of the provider's reconciliations. Once the VA establishes eligibility and adverse conditions with the veteran, the Law permits payment to the provider. The business process includes the execution of two contracts. The first, between the VA and the veteran, establishes rights to benefits. The second, between the VA and the provider, provides the benefit payout.
The statute means:
When the veteran’s insurance company pays a provider the insurance’s
share of copayment, the VA will not pay back a veteran for the money insurance
paid to a provider. That is all it means, that is all it can mean. It is elegant.
When the veteran’s insurance company pays a provider the insurance’s
share of copayment, the VA will not pay back a veteran for the money insurance
paid to a provider. That is all it means, that is all it can mean. It is elegant.
1. The Law prevents a veteran from double-dipping on an insurance copayment. The veteran cannot file for reimbursement using the insurance copay as the veteran's money.
2. The Law does not include the term deductible.
3. Without a reimbursement invoice, Form 10-7078, the rest of the statute is meaningless.
Explanation:
With any insurance, the insured contracts with an insurance company to reduce the insured payout on claims against the insured. When insurance pays out, the money belongs to the insured. Without the statute, the veteran can claim the insurance share of the copay is the veteran's money, and the veteran can invoice for reimbursement. Statute, 38 USC 1725 (f)(3), is specific, third party (veteran, provider, insurance) means the insurance company and the veteran is responsible for the insurance contract. That responsibility means the veteran has title to the insurance payout.
With any insurance, the insured contracts with an insurance company to reduce the insured payout on claims against the insured. When insurance pays out, the money belongs to the insured. Without the statute, the veteran can claim the insurance share of the copay is the veteran's money, and the veteran can invoice for reimbursement. Statute, 38 USC 1725 (f)(3), is specific, third party (veteran, provider, insurance) means the insurance company and the veteran is responsible for the insurance contract. That responsibility means the veteran has title to the insurance payout.
The VA lie. The VA regulation twisted the statute to mean the insured copay and the provider as the 3rd party. VA policy uses a self-centric relationship with other parties by claiming to be the 1st party (VA, vet, provider). The Law clearly defines a third-party as an insurance company. Note: third-party is a statue defined term, the words cannot be interpreted as a contract principal relationship with the DVA. By term's definition, the veteran must the first principal and the community provider must be the second principal. And the statute defines who the third parties can be. The definition includes "A person or entity obligated to provide or to pay the expenses of, health services under a health-plan contract." The expense of insurance is the premium cost. Payment of the premium establishes the insured, the veteran, has title to the money. The VA contrived the term expense to mean medical expense, which is a fee for a medical expense.
Title 38 USC 1725 includes other statutes the OIG report ignored. For an episode of care, a medical expense is a fee for a service. The VA fee payout is the maximum allowable amount (MAA). The VA uses the Medicare fee as the MAA and payment of the MAA exhausts other fees for the service. The stack of papers in the OIG is because the VA does not have proper data systems to calculate a VA explanation of benefits. The Law requires all payments be reconciled before invoicing the VA. The invoice form does not include an entry for other payments. Without the data for the payments, the VA cannot determine the VA responsibility amount for the MAA. Consequently, staff intervenes on every claim. And the paperwork stack piles up.
The OIG report fixes nothing. It just creates more unnecessary procedures. Changing the regulation to be compliant with the Law will have an immediate self-correcting system-wide waterfall effect. The OIG report insists the recommendations use the same audit standards derived from a fanciful regulation. But the standards are wrong! An invalid standard makes the audit invalid.
Big Note: The payout from a veteran's private health care plan is the property of the veteran. The veteran is the policyholder, the insured. A company may assist with the plan's premiums and broker policy terms, but the policy and the payout belong to the insured. If the insurer makes copayments to a provider, the insurer acts at the insured agent for the payment. As the insured's agent, the insurance payment is the property of the insured and the payment is the same as if the insured wrote a check to the provider.
Bureaucratic Racketing
The regulation says:
CFR § 17.1002 ...will be made only if all of the following conditions are met:
(d) At the time the emergency treatment was furnished, the veteran was enrolled in the VA health care system and had received medical services under the authority of 38 U.S.C. chapter 17 within the 24-month period preceding the furnishing of such emergency treatment;
The Law says:
(1)A veteran referred to in subsection (a)(1) is an individual who is an active Department health-care participant who is personally liable for emergency <tr><td><span style="vertical-align: inherit;"><span style="vertical-align: inherit;">Patient & ProviderC</span></span></td><td>Patient</td><td>Provider</td><td>Other Provider</td></tr>treatment furnished the veteran in a non-Department facility.
(2)A veteran is an active Department health-care participant if—
(A)the veteran is enrolled in the health care system established under section 1705(a) of this title; and
(B)the veteran received care under this chapter within the 24-month period preceding the furnishing of such emergency treatment.
DVA's translation of the Law into regulations has two motives, permission or denial. The DVA has business controls payout of the Federal Budget. The DAV's business motive is to limit the payout, therefore regulations tend to establish rules that deny a payout.
This statute should not be in the Title. Somebody from the DVA must have lobbied Congress to have it become Law. Because the episode of care is emergency treatment, the two-year requirement has no medical motive. As a business requirement, the statute and the regulation is bureaucratic racketing. Neither makes business sense, the DVA does not spend the budget for healthy veterans.
A Law may be interpreted in one of two ways, graning permission or preventing permission. The DVA as a business makes rules to limit payout; therefore, the DVA's perspective will use regulations to deny the veteran's benefit payout for services.
A reason for this statute and regulation is for some self-fulfilling leverage to justify active DVA client count. No medical reason exists.
OIG 11 Recommendations
For each recommendation is a jelly bean tag that exposes the nonsense in the recommendation. While the intent of the recommendation has some merit meant to improve business processes, the means test fails due to faults in the standards that contribute to the reason for a recommendation in the first place.1. The Under Secretary for Health reevaluates all claims denied after April 8, 2016, for the reason of “other health insurance” for appropriate corrective action. --- jelly beans*. What are there corrective actions, who writes this nonsense?
2. Veterans Appeals Improvement and Modernization Act of 2017, Pub. L. No. 115-55. 22 Recommendations directed to the Under Secretary for Health were submitted to the Executive in Charge, who has the authority to perform the functions and duties of the Under Secretary for Health. --- jelly beans - nothing fixes the regulation.
3. The Under Secretary for Health develops and implements control to ensure claims processors have the appropriate options in the claims-processing system of record to request evidence necessary to substantiate third-party liability claims. --- more jelly beans. Staff already has control procedures and they are stuck with jelly beans.
4. The Under Secretary for Health reevaluates all sample claims identified in this audit as inappropriately denied and rejected for appropriate corrective action. --- jelly beans staff uses the same reasons for denial the VA will not pay the copay per regulations.
5. The Under Secretary for Health reevaluates production targets, work production credits, and application of non-processing time for voucher examiners to ensure the production targets include claims research. --- use good business practice even to make jelly beans? Sure redefine targets so the business can melt jelly beans.
6. The Under Secretary for Health requests and ensures the Office of Resolution Management conduct an organizational assessment of the Claims Adjudication and Reimbursement processing locations where staff reported they were directed or encouraged to improperly process claims and to take appropriate action. --- yahoo! management can hawk jelly beans in a bigger bag.
7. The Under Secretary for Health implements strategic plans to ensure the Office of Community Care, Claims Adjudication and Reimbursement Directorate, emphasizes the accuracy of claims-processing decisions. --- the strategic plan is to invent more flavors for jelly beans. Reimbursement Directorate? The VA uses the term reimbursement as some type of spiritual gratuity.
8. The Under Secretary for Health implements controls to ensure eligibility for overtime, telework, and annual performance bonuses for Claims Adjudication and Reimbursement staff includes all facets of performance --- jelly bean manufactures know quality is the perceived use of labor, facilities, finance, and delivery. jelly beans have quality standards. Is the OIG telling the VA management to implement quality controls?
9. The Under Secretary for Health develops and implements a clearly defined and effective quality assurance program that encompasses all claims decisions and includes a standardized process for supervisors to determine and effectively monitor the extent to which claims processors accurately rejected and denied non-VA emergency care claims. --- in jelly bean manufacturing production requires cost, schedule, and quality be balanced. Cost is the resource expense or man (labor), money, materials, and machines. Schedule means delivery of a quantity within a timeframe. Quality is the perception of the use of resources and of delivery fulfillment. Quality assurance is a matrix management strategy. Before adding more staff, correct the tactical problems that caused the problems. The VA business is the distribution of money to pay a veteran's benefit. The information processing behind the distribution operation is a production business. The VA's quality assurance basis is compliance to the Law, not more staff.
10. The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities routinely communicate backlogs of incoming mail to Office of Community Care leaders with associated action plans to accurately record the date the documents were received. --- So the OIG wants more VA staff? When the VA implements a business process, the result is more jelly beans.
11. The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities and VA medical centers timely communicate claims decisions to veterans and providers to ensure veterans are notified of what VA needs to adjudicate the claims and what actions the veteran may take in response. --- the Law clearly states what information the VA needs to pay ER claims. The VA's business failure is not generating an Explanation of Benefits for every invoice. Privacy Law prohibits the VA from demanding details of a private contract between the patient, the provider and the patient's insurance company. This recommendation is so far off any business sense, it cannot receive a jelly bean.
If I was a priest, I would tell the OIG to say three Hail Marys, a good Act of Contrition, and offer absolution after replacing jelly beans with right conduct.
On page 11 is a footnote:
18 Under 38 U.S.C. § 1728, VA acts as a secondary payer when a third party is financially responsible for coverage of emergency treatment expenses received for service-connected conditions. Third-party means veteran, provider, other payers like private health insurance.
In some cases, under 38 U.S.C. § 1725, VA may, the Law says "shall be the secondary payer", act as a secondary payer, when certain third-party liability exists for emergency treatment received for nonservice-connected conditions (e.g., situations involving auto insurance or workers’ compensation claims). For such instances, VA coverage is limited to the amount for which the veteran is personally liable after the amount of third-party coverage (e.g., exhausting coverage of automobile personal injury protection insurance coverage). The Bulletin, 3, no. 13 (June 26, 2014), states the rejection reason included “clarification of auto insurance vs. other 3rd party liability processes and requirements. It is imperative that sites utilize this rejection reason and forward the letter prior to denying a claim for third party liability.”
Because the OIG does not understand the business transactions, the OIG cannot see the truth behind the problems the report identifies. 38 USC 1725 requires the VA to either pay-the-provider or reimburse-the-veteran. In either case, contracts must exist to make payments. Money transfers depend on at least five contracts, two government and three private: veteran & VA, VA & provider, and patient & provider, insured & insurer, provider & insurance. The contract between the VA and veteran are two separate agreements. Title 38 defines the first agreement by granting benefits to the veteran, and the Congress assigns the VA as its agent to use the Federal Budget to pay for the benefits. This agreement is a pay-the-provider condition.
Reimburse-the-veteran is a separate agreement because the veteran pays the provider, and the VA pays back the veteran. Under pay-the-provider, the provider invoices the VA. Under reimburse-the-veteran, the veteran invoices the VA. Both agreements meet Congress's intended use of the money, but follow-the-money is different. The Law prohibits the veteran from invoicing the VA for the insurance's share of copayment. The Law instructs the provider to reconcile all payouts before invoicing the VA.
Warning. Because the veteran-patient does not have the Law instructing the provider to reconcile other payouts, the provider can invoice the patient for the full medical expense. As an ethical business practice, the provider will reconcile before invoicing the patient. If the provider has an in-network agreement with the insurance company, and the only payout is from the insurance company, the patient will be charged the unpaid medical expenses. Under pay-the-provider, the VHA limits the provider's medical expense payout to the MAA. Under reimburse-the-veteran Congress assigns the payout limit to the Secretary. DANGER. The MAA is lower than the provider can charge the patient, and if the Secretary chooses the payout limit for reimburse-the-veteran, the veteran will not recover the full amount paid to the provider.
Congress assigns the VA the responsibility for the veteran's share of the Federal budget, a follow-the-money analysis tracks the sequence of payouts.
Pay-the-provider Track Steps:
1. veteran registers with VA
2. insurance and provider determine in-network fees.
3. insurance invoices insured
4. insured pays the insurance premium
5. provider invoices insurance
6. insurance pays provider per explanation of benefits
7. provider invoices VA
8. VA determines the maximum allowable amount
9. VA pays provider
Each step has multiple eligibilities, dependencies, constraints and other conditions that affect the flow of money. Each invoice is a request to transfer title to money. Each payment is a transfer of the title to the money.
The OIG reports details some of the VA's administrative problems during Step 8.
Step 8 not only determines the maximum allowable amount (MAA); it also exhausts further provider fees for the same service.
The Latrine Detail
For some reason the VA considers reimbursement to be some type of gratuitous spiritual act. Reimbursement is a business transaction. Rather than following a business process, the VA presupposes a condition, like the veteran, has private insurance and the VA has rights right to the terms of the private insurance, that the VA claims to be an immediate basis for the denial.
The latrine detail is a name for the VA bypassing the reimburse-the-veteran process. The VA considers reimbursement to be a type of spiritual gratuitous act and grants themselves diety procedures including the purported right to demand information from the provider about private contract terms the provider has with other parties.
The OIG report reflects the consequences of not understanding reimbursement is a formal business process.
Reimburse-the-veteran steps:
1. Steps 1-7 are the same as pay-the-provider.
2. VA denies provider invoice
3. Provider invoices patient per insurance EOB
4. Patient pays provider
5. Veteran invoices VA
6. VA pays the veteran the maximum allowable amount.
7. If the patient's insurance unpaid copay is greater than the MAA. the veteran cannot recover the out-of-pocket difference cost.
The difference between what the veteran paid the provider and what the VA will pay based the MAA is the latrine deposit. In a data sample comparing an insurance copayment compared to Medicare fee for the same service, the VA would have paid several thousand less than the insurance copay. Plus, if the patient paid the patient copay, that is more money in the latrine.
MAA - other payment = MPA where MPA "extinguish any liability on the part of the veteran for that treatment." The Law does not use the term MPA, but invoice and payment are business transaction terms related to money. An invoice is a demand for a title for some dollar amount. Payment is the money transfer of the title for the invoice amount.
The Law states the most the government can pay for the veteran's medical expense is the MAA. The medical needs event determines the business rules for a patient's medical costs. The event creates a medical services episode-of-care wherein care requires one or more treatments wherein a treatment requires one or more medical services. Each cost for a service the medical expense. The definition of a medical expense is the fee for the service. For billing purposes, each medical expense has a Current Procedural Terminology (CPT) code. The American Medical Association determines the code for each medical expense. However, the code itself does not state a cost. Medicare does state the MAA and the MAA equals the MPA. The Law limits veteran medical expense cost to the Medicare MAA.
The CPT lists thousands of medical services, but not all. And, the provider's medical tend to be more than the Medicare MAA. The
Even the IRS, 26 USC 213 puts rules on medical care.
1. Case: where other payments is more than the MAA
If MAA - other payments less than or equal zero, then MPA is zero.
2. Case: where the veteran has no HCP or other payment,s are s zero:
If MAA - other payments equal MAA MP then MPA = MAA.
3. Case: where other payments pay some to the MAA.
If MAA - other payments less than MAA then MPA = MAA - other payments.
In all three cases per 1725(c)(3), the VA's payment exhausts other charges by the provider.
In order for the VA to calculate the MPA, the VA needs the amount other payments contributed to the MAA. The current VHA rules instruct VHA staff to demand the patient's private property of the HPC explanation-of-benefits. That demand is illegal.
Bad data, bad VA
A critical document in the follow-the-money process is the data on the invoice the provider or veteran submits to the VA. The cost of an episode of care is a medical treatment that involves one or more medical expenses. A medical expense is a fee for a service.
In order for the VA to calculate payout, the VA needs:
a. the fee for unpaid medical expenses
b. the medical service code
c. total of other payouts for the service
The current Form 10-7078 only includes the unpaid medical expense for the service. By Law, the provider must reconcile other payouts before invoicing the VA.
By Law, all payouts for the same medical expense reduce the MAA the VA can pay. The invoice form does not have a data entry that totals other payouts for the same service. Without the provider including the total, every invoice requires manual intervention.
Please fix it
General, you should go kick some ass. Since 1968 when the Corps started my career in the computers until today, the VA has the single biggest data blunder in my 50 years of experience. All the jelly beans in your report did not identify the VA's failure to follow the law with third party payment.
I am going to give you a million-dollar consulting fee for FREE. Change the provider's invoice form to include a single data field. accumulated payments. With that single value, the jelly beans turn to water. Yep, the field is not in medicare codes. The DVA and Medicare do not use the same payout rules.
Get some of those IT staff busy doing software for indirect cost recovery and for an automated explanation of benefits and a little artificial intelligence for veteran eligibility, so the DVA can clean its mess. The DVA reports direct cost recovery as revenue but does not report indirect cost recovery.
The first job is to publish the electronic data format for the new field, provider IT will be happy to update their side. The books will balance faster.
The OIG report's recommendations aid in grief experience relief. Unless the OIG and the Secretary take action to close the wound that caused the trauma in the first place, the reconnections are like sand in an hourglass.
I. Correct the regulation
II. Recognize reimbursement is a formal business process.
III. Change the invoice form to include other payouts.
IV. Respect private contracts
V. Honor the Goodwill Grant as private to the VA and not shared with others unless the use is for VA medical services.
General, here is a crazy simple fix.
If a veteran has a private health plan contract for medical insurance, the Goodwill Grant is the veteran's volunteered permission of the veteran's private health insurance for VA's direct cost recovery at VA facilities. 38 U.S. Code § 1729 - Recovery by the United States of the cost of certain care and services.
In some cases, under 38 U.S.C. § 1725, VA may, the Law says "shall be the secondary payer", act as a secondary payer, when certain third-party liability exists for emergency treatment received for nonservice-connected conditions (e.g., situations involving auto insurance or workers’ compensation claims). For such instances, VA coverage is limited to the amount for which the veteran is personally liable after the amount of third-party coverage (e.g., exhausting coverage of automobile personal injury protection insurance coverage). The Bulletin, 3, no. 13 (June 26, 2014), states the rejection reason included “clarification of auto insurance vs. other 3rd party liability processes and requirements. It is imperative that sites utilize this rejection reason and forward the letter prior to denying a claim for third party liability.”
Follow-the-money
Attention to orders Inspector General: Any time the term money occurs inspect its use for title, value, use, and asset. Make a mental note of this example: I {title} have $10 {$ dollars asset} 10 {value} in the bank {use}. And if you can think just a little more, an invoice is a demand for money's title to pay for goods or services. Payment is the transfer of title to invoicer. Follow-the-money means to follow the title. Value, asset, and use are audit conditions.Because the OIG does not understand the business transactions, the OIG cannot see the truth behind the problems the report identifies. 38 USC 1725 requires the VA to either pay-the-provider or reimburse-the-veteran. In either case, contracts must exist to make payments. Money transfers depend on at least five contracts, two government and three private: veteran & VA, VA & provider, and patient & provider, insured & insurer, provider & insurance. The contract between the VA and veteran are two separate agreements. Title 38 defines the first agreement by granting benefits to the veteran, and the Congress assigns the VA as its agent to use the Federal Budget to pay for the benefits. This agreement is a pay-the-provider condition.
Reimburse-the-veteran is a separate agreement because the veteran pays the provider, and the VA pays back the veteran. Under pay-the-provider, the provider invoices the VA. Under reimburse-the-veteran, the veteran invoices the VA. Both agreements meet Congress's intended use of the money, but follow-the-money is different. The Law prohibits the veteran from invoicing the VA for the insurance's share of copayment. The Law instructs the provider to reconcile all payouts before invoicing the VA.
Warning. Because the veteran-patient does not have the Law instructing the provider to reconcile other payouts, the provider can invoice the patient for the full medical expense. As an ethical business practice, the provider will reconcile before invoicing the patient. If the provider has an in-network agreement with the insurance company, and the only payout is from the insurance company, the patient will be charged the unpaid medical expenses. Under pay-the-provider, the VHA limits the provider's medical expense payout to the MAA. Under reimburse-the-veteran Congress assigns the payout limit to the Secretary. DANGER. The MAA is lower than the provider can charge the patient, and if the Secretary chooses the payout limit for reimburse-the-veteran, the veteran will not recover the full amount paid to the provider.
Congress assigns the VA the responsibility for the veteran's share of the Federal budget, a follow-the-money analysis tracks the sequence of payouts.
Pay-the-provider Track Steps:
1. veteran registers with VA
2. insurance and provider determine in-network fees.
3. insurance invoices insured
4. insured pays the insurance premium
5. provider invoices insurance
6. insurance pays provider per explanation of benefits
7. provider invoices VA
8. VA determines the maximum allowable amount
9. VA pays provider
Each step has multiple eligibilities, dependencies, constraints and other conditions that affect the flow of money. Each invoice is a request to transfer title to money. Each payment is a transfer of the title to the money.
The OIG reports details some of the VA's administrative problems during Step 8.
Step 8 not only determines the maximum allowable amount (MAA); it also exhausts further provider fees for the same service.
The Latrine Detail
For some reason the VA considers reimbursement to be some type of gratuitous spiritual act. Reimbursement is a business transaction. Rather than following a business process, the VA presupposes a condition, like the veteran, has private insurance and the VA has rights right to the terms of the private insurance, that the VA claims to be an immediate basis for the denial.
The latrine detail is a name for the VA bypassing the reimburse-the-veteran process. The VA considers reimbursement to be a type of spiritual gratuitous act and grants themselves diety procedures including the purported right to demand information from the provider about private contract terms the provider has with other parties.
The OIG report reflects the consequences of not understanding reimbursement is a formal business process.
Reimburse-the-veteran steps:
1. Steps 1-7 are the same as pay-the-provider.
2. VA denies provider invoice
3. Provider invoices patient per insurance EOB
4. Patient pays provider
5. Veteran invoices VA
6. VA pays the veteran the maximum allowable amount.
7. If the patient's insurance unpaid copay is greater than the MAA. the veteran cannot recover the out-of-pocket difference cost.
The difference between what the veteran paid the provider and what the VA will pay based the MAA is the latrine deposit. In a data sample comparing an insurance copayment compared to Medicare fee for the same service, the VA would have paid several thousand less than the insurance copay. Plus, if the patient paid the patient copay, that is more money in the latrine.
Maximum Allowable Amount Calculation
The Law details the DVA's payout for ER treatment:
38 USC 1725 IS A(c)Limitations on Reimbursement.—
(1)The Secretary, in accordance with regulations prescribed by the Secretary, shall—
(A)establish the maximum amount payable under subsection (a);
(B)delineate the circumstances under which such payments may be made, to include such requirements on requesting reimbursement as the Secretary shall establish; and
(C)provide that in no event may a payment under that subsection include any amount for which the veteran is not personally liable.
(c) (3)Payment by the Secretary under this section on behalf of a veteran to a provider of emergency treatment shall, unless rejected and refunded by the provider within 30 days of receipt, extinguish any liability on the part of the veteran for that treatment. Neither the absence of a contract or agreement between the Secretary and the provider nor any provision of a contract, agreement, or assignment to the contrary shall operate to modify, limit, or negate the requirement in the preceding sentence.
" in accordance with regulations prescribed by the Secretary" mean A, B. C applies.
"establish the maximum amount payable" uses payment amount based on the Medicare medical expense. If Medicare does not have a service code, the VA defines its own. A maximum allowable amount (MAA) is an invoice amount and it also means the maximum payable amount (MPA) payment. If the VHA published an explanation-of-benefits, like HCP publishes, the calculation is:
MAA - other payment = MPA where MPA "extinguish any liability on the part of the veteran for that treatment." The Law does not use the term MPA, but invoice and payment are business transaction terms related to money. An invoice is a demand for a title for some dollar amount. Payment is the money transfer of the title for the invoice amount.
The Law states the most the government can pay for the veteran's medical expense is the MAA. The medical needs event determines the business rules for a patient's medical costs. The event creates a medical services episode-of-care wherein care requires one or more treatments wherein a treatment requires one or more medical services. Each cost for a service the medical expense. The definition of a medical expense is the fee for the service. For billing purposes, each medical expense has a Current Procedural Terminology (CPT) code. The American Medical Association determines the code for each medical expense. However, the code itself does not state a cost. Medicare does state the MAA and the MAA equals the MPA. The Law limits veteran medical expense cost to the Medicare MAA.
The CPT lists thousands of medical services, but not all. And, the provider's medical tend to be more than the Medicare MAA. The
Even the IRS, 26 USC 213 puts rules on medical care.
1. Case: where other payments is more than the MAA
If MAA - other payments less than or equal zero, then MPA is zero.
2. Case: where the veteran has no HCP or other payment,s are s zero:
If MAA - other payments equal MAA MP then MPA = MAA.
3. Case: where other payments pay some to the MAA.
If MAA - other payments less than MAA then MPA = MAA - other payments.
In all three cases per 1725(c)(3), the VA's payment exhausts other charges by the provider.
In order for the VA to calculate the MPA, the VA needs the amount other payments contributed to the MAA. The current VHA rules instruct VHA staff to demand the patient's private property of the HPC explanation-of-benefits. That demand is illegal.
Bad data, bad VA
A critical document in the follow-the-money process is the data on the invoice the provider or veteran submits to the VA. The cost of an episode of care is a medical treatment that involves one or more medical expenses. A medical expense is a fee for a service.
In order for the VA to calculate payout, the VA needs:
a. the fee for unpaid medical expenses
b. the medical service code
c. total of other payouts for the service
The current Form 10-7078 only includes the unpaid medical expense for the service. By Law, the provider must reconcile other payouts before invoicing the VA.
By Law, all payouts for the same medical expense reduce the MAA the VA can pay. The invoice form does not have a data entry that totals other payouts for the same service. Without the provider including the total, every invoice requires manual intervention.
Please fix it
General, you should go kick some ass. Since 1968 when the Corps started my career in the computers until today, the VA has the single biggest data blunder in my 50 years of experience. All the jelly beans in your report did not identify the VA's failure to follow the law with third party payment.
I am going to give you a million-dollar consulting fee for FREE. Change the provider's invoice form to include a single data field. accumulated payments. With that single value, the jelly beans turn to water. Yep, the field is not in medicare codes. The DVA and Medicare do not use the same payout rules.
Get some of those IT staff busy doing software for indirect cost recovery and for an automated explanation of benefits and a little artificial intelligence for veteran eligibility, so the DVA can clean its mess. The DVA reports direct cost recovery as revenue but does not report indirect cost recovery.
The first job is to publish the electronic data format for the new field, provider IT will be happy to update their side. The books will balance faster.
The OIG report's recommendations aid in grief experience relief. Unless the OIG and the Secretary take action to close the wound that caused the trauma in the first place, the reconnections are like sand in an hourglass.
I. Correct the regulation
II. Recognize reimbursement is a formal business process.
III. Change the invoice form to include other payouts.
IV. Respect private contracts
V. Honor the Goodwill Grant as private to the VA and not shared with others unless the use is for VA medical services.
General, here is a crazy simple fix.
If a veteran has a private health plan contract for medical insurance, the Goodwill Grant is the veteran's volunteered permission of the veteran's private health insurance for VA's direct cost recovery at VA facilities. 38 U.S. Code § 1729 - Recovery by the United States of the cost of certain care and services.
General, The DVA Has No First Principles.
Everywhere we go and everything we do, we process translations. Right now you are translating these symbols into thoughts. To calculate 1 + 1 = 3, you learn the + and = are the first principles of arithmetic. First-principles are everywhere except at the DVA. When the DVA translatesTitle 38 statutes into regulations, the DVA has no first-principles.
Rather than trying to explain, I am just going to give you 25 first principles. Think of each principle as a correctness filter between the Law and the regulation. You know the expression, it goes in one ear and out the other. First-principles provide a listening gate.
This is a list of first principles. The list begins with the missing definition for Title 38.
- Title 38 USC Veterans' Benefits is Congress's lifetime wellness grant of benefits to each honorably discharged veteran for the veteran's national service with the Department of Defense.
- Title 38 statutes define the grant's services.
- Congress allocates funds from the Federal Budget to pay the fees for the services.
- A veteran's benefit is the paid fee for a Title 38 service.
- By Law, the veteran owns all benefits.
- The DVA and the Broad of Veteran Appeals are Title 38 services
- Veteran disability compensation is a Title 38 service.
- The DVA is an agent of Congress to administer the Budget's allocation and to provide Title 38 services.
- Title 38 is a set of business rules for Title 38 payouts.
- Once a veteran always a veteran.
- To receive Title 38 services, the veteran must register as a client with DVA.
- The DVA is not a veteran, therefore the DVA cannot own benefits.
- The DVA is an agency, not a club, veterans are clients, not members.
- In all agreements between the veteran and the DVA, the veteran is always the first party principal.
- For veteran's medical treatments at a community provider, the DVA establishes an expressed agency with the provider thereby the medical expense is the same as if the treatment occurred at a DVA facility.
- A medical expense is a fee for medical service.
- Treatment for an episode of care may include one or more medical expenses. Medical trauma may include one or more episodes of care.
- The purpose of insurance is to reduce the insured liability. The payout from the insurer is the insured's property.
- An insurance company may act the insured's agent to make a claim payments. The payment is exactly the same as if the insured paid the claim.
- The Goodwill Grant is the veteran's volunteered permission given to the DVA to used the veteran's private insurance for cost recovery at a DVA faculty. The grant permits the DVA to be a principal to make cost recovery claims with the insurer.
- The DVA has a fiduciary trust responsibility to use the Goodwill Grant's private information only within the DVA and not with any DVA's agents.
- The DVA may assist Congress in determining a veteran's eligibility for a particular service, once eligible, the DVA cannot deny the service as a veteran's benefit.
- All veterans at the time of active duty discharge are eligible for Title 38 benefits and may register with the DVA for Title 38 services.
- The DVA cannot deny an honorably discharged as a client.
- The veteran has the responsibility to use Title 38 services for the veteran's wellness.
The Business of Title 38 Benefits
The definition of a veteran's benefits is the paid fee for a Title 38 service. Congress's allocation from the Federal Budget pays the benefit fee. For any money transfers, contacts between principals include invoices and payments.
For a community care emergency treatment episode-of-care, behind 38 USC 1725 are many contracts.
Principals: veteran, DVA, provider, patient, HPC, other payers, other providers
- For community care, DVA is disjoint from the patient's HPC.
- *For VHA in-facility, the Goodwill Grant limits veteran's HCP as a 3rd Party for VHA cost recovery. The veteran's HCP is the veteran's agent for making payments to VHA.
HIPPA is for medical information not for business reporting. DVA as the veteran's medical provider has access to HIPPA.
I am not a lawyer, I am a good information analyst. Everybody is an information modeler. When a patient sees a doctor, the patient's normal information model experiences trauma. The doctor uses medical information models to create an affinity information model about the trauma to create a diagnosis information model.
An information analyst uses diagnostic and affinity tools to develop models for information science. When analyzing commercial business processes, contracts provide a formal definition of activity between two principals. A principal can one and individual or group acting as an individual. A follow-the-money analysis tracks the title to money across contracts. An invoice is a demand to transfer title to money. Payment is a transfer of title to the money.
Title 38 Veterans' Benefits is a grant to a veteran for national service. The Federal Budget pays for government operations. Congress assigns the DVA to be Congress's agent to use the Federal Budget to pay for the veteran's benefits. Title 38 is a set of business rules Congress approved for the money's use. By following the business rules, the VA is a formal business activity. Behind 1725 is a least 5 contracts, VA & veteran, patient & provider, insured & insurer, provider & insurer, VA & provider where the title to money crosses.
*jelly beans - the candy is firm and colorful on the outside, but soft and squishy on the inside. In writing, a jelly bean is a comment about a statement that uses words that appear solid but lacks substance behind the words.
Comments
Post a Comment
Thank you for your comment.