GrantRobertson
Well-known member
I currently work at the VA Financial Services Center, processing medical claims. I am learning a few things that I think can help veterans avoid getting stuck with medical bills they thought the VA would pay. All of these tips apply only to receiving health care NOT at a VA hospital or clinic (which I expect all of us on this forum to need to do from time to time).
Most of these tips also do not apply if you go to an outside provider through the Choice program. If you are a veteran who is eligible to go to the VA hospital, you should have already received information about the Choice program. If not, I can post info about that program later.
A) If you think you may ever possibly need to receive health care outside of the VA system, make sure to go to a VA hospital or clinic a minimum of once every two years. Make up a reason If you have to. If you have not been seen at a VA facility within 24 months before the date you end up needing care outside the VA, then the VA will deny the claim from the provider. You will be stuck paying the entire bill.
B) Make sure that outside provider submits the claim to the VA right away. Depending on your service-connected-disability status, if the claim is not submitted within 90 days or 2 years, then the VA will deny the claim for "untimely filing." You may not think this would be a problem, but we commonly see claims submitted past the deadline. If a provider can't get their claims submitted with important information correct, then the VA will keep returning them for correction. Only the final, correct claim submission date counts. This is where polite micromanagement can come in handy. Unfortunately, due to the large backlog, it can take the VA almost, or even past the deadline to get around to looking at the first submitted claim to see if it is correct or needs to be returned. So, by the time a corrected claim is submitted it could be well past the deadline. Again, you will be stuck with the bill. In fact, you could be surprised with a bill years after you received care.
In fact, if it were me, I would ask to review the claim from the provider BEFORE they even submit it to the VA. Make sure all your information is correct. Make sure the vendor name is accurate. Make sure everything is legible and all the data fits cleanly within the appropriate fields on the form. Make sure the data, and only the data, is printed in black and that the form itself is pre-printed in red. These forms are scanned into a computer database and that whole process is not necessarily accurate. If the form itself (the lines, field names and stuff) is in black instead of red, it makes recognizing the data very difficult for the scanner. Sometimes it is possible for claims to be returned even IF the information is correct, if it isn't caught and fixed at the VA. We try to catch and fix as much as possible but we aren't perfect.
At this time, I know of no way to contact the VA to check on the status of that claim. So your only option is to do everything possible to make sure the claim is perfect before it is sent to the VA.
C) If you have other insurance, make sure the care provider submits claims to them first. The VA will only pay what is left over AFTER the other insurance providers have paid their part.
D) You MUST notify the VA within 72 hours, before or after your dates of service. Often, the other hospital will automatically make the notification. However, never trust that that will happen. Call the VA hospital nearest where you received care yourself. Tell them the "Dates of Service," which are the days you received care. If possible, get them to give you the 'Clinical Tracking Record" number of this "Episode of Care." If they can't or won't, then at least get their name and department. Again, if it were me, I would call in the next day and talk to a different person, then ask them to check that your "72 hour Notification" was entered for the "Clinical Tracking Record" for this specific "Episode of Care." Again, if there is no notification, the VA will deny the claim and stick you with the bill.
E) Look for health care providers who are willing to bill ONLY the amount Medicare pays. Sometimes called The "CMS rate." The VA will only pay this amount. Though, if this amount is what is left over AFTER your other insurance pays their part, then the VA will pay that leftover amount up to the CMS rate. It still always pays to check with the provider before you go. In my personal experience, if a provider won't promise that they only charge the Medicare rates, then they charge a lot more, regardless of any other BS they tell you.
OK, that is all I can think of for now. I'm sorry if this came out a little jumbled and disorganized. I wrote most of it on my phone while waiting for the computer systems to stop screwing up during my training class.
Most of these tips also do not apply if you go to an outside provider through the Choice program. If you are a veteran who is eligible to go to the VA hospital, you should have already received information about the Choice program. If not, I can post info about that program later.
A) If you think you may ever possibly need to receive health care outside of the VA system, make sure to go to a VA hospital or clinic a minimum of once every two years. Make up a reason If you have to. If you have not been seen at a VA facility within 24 months before the date you end up needing care outside the VA, then the VA will deny the claim from the provider. You will be stuck paying the entire bill.
B) Make sure that outside provider submits the claim to the VA right away. Depending on your service-connected-disability status, if the claim is not submitted within 90 days or 2 years, then the VA will deny the claim for "untimely filing." You may not think this would be a problem, but we commonly see claims submitted past the deadline. If a provider can't get their claims submitted with important information correct, then the VA will keep returning them for correction. Only the final, correct claim submission date counts. This is where polite micromanagement can come in handy. Unfortunately, due to the large backlog, it can take the VA almost, or even past the deadline to get around to looking at the first submitted claim to see if it is correct or needs to be returned. So, by the time a corrected claim is submitted it could be well past the deadline. Again, you will be stuck with the bill. In fact, you could be surprised with a bill years after you received care.
In fact, if it were me, I would ask to review the claim from the provider BEFORE they even submit it to the VA. Make sure all your information is correct. Make sure the vendor name is accurate. Make sure everything is legible and all the data fits cleanly within the appropriate fields on the form. Make sure the data, and only the data, is printed in black and that the form itself is pre-printed in red. These forms are scanned into a computer database and that whole process is not necessarily accurate. If the form itself (the lines, field names and stuff) is in black instead of red, it makes recognizing the data very difficult for the scanner. Sometimes it is possible for claims to be returned even IF the information is correct, if it isn't caught and fixed at the VA. We try to catch and fix as much as possible but we aren't perfect.
At this time, I know of no way to contact the VA to check on the status of that claim. So your only option is to do everything possible to make sure the claim is perfect before it is sent to the VA.
C) If you have other insurance, make sure the care provider submits claims to them first. The VA will only pay what is left over AFTER the other insurance providers have paid their part.
D) You MUST notify the VA within 72 hours, before or after your dates of service. Often, the other hospital will automatically make the notification. However, never trust that that will happen. Call the VA hospital nearest where you received care yourself. Tell them the "Dates of Service," which are the days you received care. If possible, get them to give you the 'Clinical Tracking Record" number of this "Episode of Care." If they can't or won't, then at least get their name and department. Again, if it were me, I would call in the next day and talk to a different person, then ask them to check that your "72 hour Notification" was entered for the "Clinical Tracking Record" for this specific "Episode of Care." Again, if there is no notification, the VA will deny the claim and stick you with the bill.
E) Look for health care providers who are willing to bill ONLY the amount Medicare pays. Sometimes called The "CMS rate." The VA will only pay this amount. Though, if this amount is what is left over AFTER your other insurance pays their part, then the VA will pay that leftover amount up to the CMS rate. It still always pays to check with the provider before you go. In my personal experience, if a provider won't promise that they only charge the Medicare rates, then they charge a lot more, regardless of any other BS they tell you.
OK, that is all I can think of for now. I'm sorry if this came out a little jumbled and disorganized. I wrote most of it on my phone while waiting for the computer systems to stop screwing up during my training class.
