• Compliance Matters

    Serving Veterans Through Community Programs

    Here's what PTs need to know about recent changes and how to sign up.

    Our nation's veterans deserve access to the care they need, within or outside Veterans Administration (VA) facilities. It is imperative, therefore, that they have timely access to comprehensive, high-quality community health care services, including physical therapy.

    The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act was enacted in 2018 to improve veterans' access to health care services. It is important that physical therapists (PTs) in private practice and other outpatient settings who treat veterans in the community—or are interested in becoming a community provider—understand how, where, and when care can be delivered.

    First, though, it's important to note the difference between VA health care and TRICARE. The Veterans Health Administration (VHA) under VA covers veterans—those who once served in the military but have retired or are now separated from service due to a service-connected illness or injury. TRICARE is a civilian network, administered by the US Department of Defense, that provides health care benefits to active-duty service members, National Guard/reserve members, and their families when services cannot be provided at a military treatment facility.

    When service members leave active duty, they may be eligible for benefits offered by either VA or TRICARE, depending on whether they have retired and/or how they separated from the military. Military retirees are eligible for TRICARE and also may be eligible for certain VA health care benefits. Service members who left the military because of a service-connected disease or injury may be eligible for VA health care benefits and for certain TRICARE benefits.

    (TRICARE rules and regulations will be the subject of an upcoming Compliance Matters column, but you can see a snapshot of the program on the facing page.)

    Eligibility for Community Care

    Generally, a veteran eligible for community care under VA may either schedule an appointment with a VA health care provider or seek VA's authorization to receive hospital care, medical services (including rehabilitation), or extended care services from an eligible entity or provider—as long as VA has determined the care or services are clinically necessary.

    Veterans may be eligible for care through a non-VA medical facility or provider in their local community depending on their health care needs or circumstances, and if they meet specific eligibility criteria. A veteran needs to meet only 1 of the following criteria to be eligible:

    • The veteran requires a service that is not available at a VA medical facility.
    • The veteran lives in state or territory that lacks a full-service VA medical facility.
    • The veteran qualifies under a “grandfather” provision related to distance eligibility under the discontinued Veterans Choice Program that preceded the current community care program.
    • The veteran would incur too far a drive or too long a wait for an appointment if he or she were to be treated at a specific VA medical facility.
    • The veteran and the referring clinician agree that it is in the veteran's best medical interest to receive community care based on established criteria including the nature, frequency, and quality of care required.
    • VA has determined that the VA medical service line that should provide the care the veteran needs is not providing care that complies with the VA's standards for quality.

    Even if veterans are eligible for community care, in general they still can choose to receive care from a VA medical facility. In most instances, veterans must get approval from VA before receiving care from a community provider to avoid being billed for that care. VA staff members generally make all eligibility determinations for community care.

    When a veteran arrives for the appointment with the community provider—we'll assume it's a PT for our purposes—the PT should have on file a record of the appointment, the VA referral or order for physical therapy, and all medical documentation. If a veteran needs a follow-up appointment, the PT should check to make sure that VA has authorized additional care before scheduling the appointment.

    VA offers 3 types of community care programs—Patient-Centered Community Care (PC3), the Community Care Network (CCN), and Veterans Care Agreements (VCA).

    PC3. Under the VA MISSION Act, VA modified a community care contract that had provided coverage under the Veterans Choice Program in order to use the same third-party administrator (TPA)—TriWest—to provide expanded nationwide community care coverage until CCN is up and running with a full network of providers. TriWest provides this coverage through PC3.

    PC3 is a nationwide network of community providers the VA uses to refer veterans to community care under specific circumstances. PC3 is intended to provide eligible veterans with access to medical care when services are not readily available or accessible at their local VA medical facility.

    TriWest performs certain functions on behalf of VA, such as scheduling appointments and paying claims. It will continue to manage PC3 through at least September 30, 2020.

    Scheduling. For a veteran to receive care from a community provider participating in PC3, TriWest or VA contacts that individual and coordinates the appointment between the provider and the veteran. After the appointment, the provider must submit medical documentation to the TPA.

    Claim submission. Once the TPA receives medical documentation, it is uploaded to the TPA portal for VA facility staff. VA staff then downloads the medical documents and places them in the veteran's electronic health record. After this process is complete, the TPA reimburses the provider for medical care provided.

    Reimbursement rates. PC3 community providers must accept Medicare reimbursement rates.

    Coverage and billing. Here are answers to commonly asked questions:

    • TriWest covers services provided by physical therapist assistants (PTAs).
    • TriWest requires that all state- and Medicare-related supervision requirements for use of PTAs (and occupational therapy assistants) be followed.
    • As APTA staff experts understand it, TriWest follows Medicare's 8-minute billing rule, but we suggest that providers verify with the contractor.

    CCN. To provide more choices and robust care coordination for veterans, the VA MISSION Act instructs VA to consolidate existing community care programs—including Patient-Centered Community Care and Veterans Choice—into a single program to eliminate the confusion veterans have faced from multiple programs and eligibility requirements. CCN will award contracts to TPAs to develop and administer regional networks of high-performing licensed health care providers, who will work with VA providers and practitioners to provide services to veterans who are unable to receive care at local VA medical centers.

    At this writing, Optum Public Sector Solutions Inc has been announced as TPA for CCN regions 1 (mainly East Coast states), 2 (Midwest), and 3 (South). TriWest has been named TPA for Region 4 (West)—with announcements pending of contractors for regions 5 (Alaska and Hawaii) and 6 (Pacific territories). For updated information, visit the CCN webpage referenced in the Resources box on page 14. You also can request updates at this address: https://public.govdelivery.com/accounts/USVHA/subscriber/new?topic_id=USVHA_124.

    Until the transition from PC3 to CCN is complete, community providers should continue to partner with TriWest. Once CCN contractors for all 6 regions have been named, those contractors will reach out to providers regarding enrollment.

    Scheduling. Under CCN, VA staff will refer veterans directly to community providers and will schedule community care appointments for veterans through the local VA medical center. Veterans also can choose to schedule their own appointment with support from local VA staff.

    Claim submission. TPAs will pay claims submitted by community providers within their network and send invoices directly to VA for reimbursement.

    Reimbursement rates. The contract will set forth terms of payment, but generally payment will not exceed the applicable Medicare fee schedule or prospective payment system amount.

    VCA. Under the VA MISSION Act, VA may enter into agreements with certain community providers who are not part of VA's contracted CCN. VCAs are intended to be used in limited situations in which VA either does not provide contracted services that veterans need through a VA facility, contractor, or sharing agreement; or in which contracted services may be available but are insufficient.

    Under this authority, VA can enter into agreements with community providers to provide hospital care, medical services—including medical examination, treatment, and rehabilitative services—or extended care services to individuals who are eligible to receive such care from a non-VA provider.

    Either a community provider or a local VA medical facility may initiate the process of establishing a VCA. (A VA medical facility may urge a community provider to enter into a VCA to fill a gap in contracted services.) Providers seeking to enter into a VCA must apply for certification. VA has 120 days from receipt of the application to approve or deny the request. Once a VCA is signed, it is active for 3 years and must be recertified every 12 months.

    Scheduling. As soon as a VCA is signed, the community provider can begin receiving referrals and authorizations from VA to provide care.

    Claim submission. Community providers submit claims directly to VA using electronic data interchange, or by mailing claims to the address contained in the referral.

    Reimbursement. The rates paid by VA for hospital care, medical services, and extended care services furnished pursuant to a VCA will be the rates set forth in the agreement. Generally, payments will not exceed the applicable Medicare fee schedule or prospective payment system amount. VA is responsible for any payment or fee arising from care authorized through VCAs. Community providers cannot collect or seek to collect payments from any entity for VA-authorized care, including from a veteran or a veteran's other health insurance.

    Gainer, Kara

    Kara Gainer, JD, is director of regulatory affairs at APTA.  

    TRICARE Facts

    Medically retired veterans who receive care for their service-connected disability at VA may be eligible to receive all of their other care through TRICARE. Under TRICARE, furthermore, veterans may choose among TRICARE Prime, Standard, and Extra plans. Their eligible family members have the same options.

    Current TRICARE contractors are Humana Military (TRICARE East Region) and Health Net Federal Services (TRICARE West Region).

    Learn more on APTA's website: www.apta.org/TRICAREVA.

    Third-Party Administrators

    To learn more about contracting with TriWest and Patient-Centered Community Care, go to www.va.gov/COMMUNITYCARE/providers/info_PC3.asp.

    To learn more about contracting with the Community Care Network, go to www.va.gov/COMMUNITYCARE/providers/Community_Care_Network.asp.

    To learn more about entering into a Veterans Care Agreement, contact your closest VA medical facility. To find the nearest one, use VA's provider locator at www.va.gov/find-locations.

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