They Need You

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Engage with candidates this campaign season.

By Alpha Lillstrom Cheng, JD, MA

It is August in an election year. While many things are uncertain in this incredible election cycle, one thing is for sure—candidates are pounding the pavement, knocking on doors, kissing babies, and eager to meet as many constituents as possible in order to earn as many votes as they can. This presents you with many opportunities to engage with those running for office while he or she is in campaign mode.

During campaign season, people running for office host events such as town hall meetings, rallies, and listening sessions. These public events are often well publicized and are the perfect opportunity to introduce yourself to the candidate and their staff. Often the local papers or news stations report on upcoming events, but the most efficient way to find out when and where an event will take place is to sign up for notices on his or her website. The process is similar for anyone running for office, but the mechanisms differ slightly because of differing levels of organization and resources a given candidate might have. Campaign websites vary widely in their sophistication and ease of use. The easiest way to find a campaign website is to search for the full name and the candidate and “campaign” in a search engine such as Google. For candidates challenging an incumbent legislator, it is often most efficient to call or stop by their campaign office and ask for the best way to get on their event mailing list. In the case of incumbent members of Congress running for reelection, there are two places to look—their campaign website and their official congressional website. Generally a sitting senator’s official website uses the following naming convention: www.senator’slastname.senate.gov; for an incumbent representative it will be www.representative’sname.house.gov. If your legislator has the same last name as another member of Congress, use their first name too; for example www.paulryan.house.gov is Speaker Paul Ryan’s official congressional website. Another way to make sure you learn of upcoming events in your area is to reach out to both the incumbent’s district and campaign offices and ask to be added to their event mailing list.

Breaking into a Narrow Network

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Beginning in 2017, health insurance plans will be classified as basic, standard, or broad network so that consumers can better understand their options.

By Alpha Lillstrom

Like any for-profit corporation, health insurance companies are in the business of providing a service—paying for care—but are also seeking to gain revenue while meeting their business obligations. With the passage of the Affordable Care Act (ACA) in 2010, the insurance companies’ previously utilized tactics for controlling cost—limiting the benefits they cover and the people they insure—were outlawed.

The ACA was also designed to educate and empower consumers and thereby required that health insurance marketplaces list insurance products side by side, using universal terminology, in order to provide consumers the opportunity to compare plans, coverage, and cost all in one forum. This transparency was intended to increase consumers’ ability to shop for an insurance plan that met their health coverage needs at a price point of their choosing. It also meant that if insurance companies increased premiums without providing enough value, they would run the risk of losing customers to lower-cost competitors. At the same time, many new exchange customers were previously uninsured; therefore, insurers had little or no information upon which to predict their use of health care. That meant that insurers could not be sure where to set premiums or how aggressively to try to control costs, including the use of limited networks of physicians and hospitals that enrollees could use.1

Locum Tenens Progress

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By Alpha Lillstrom

The staffing challenges of a small private practice are familiar to many: If you are unavoidably absent from your practice, it is likely that you have insufficient staff to cover all of the Medicare patients you have on the schedule. Unlike many private payers who will accept a substitute therapist or locum tenens provider, Medicare does not allow physical therapists to bring in a qualified substitute to provide care in the absence of a physical therapist enrolled at that clinic location. Instead, you must cancel appointments—interrupting their care and your cash flow. If you want to use a visiting physical therapist, that individual must already be credentialed by Medicare for your specific practice.

Progress Toward Reimbursement for Telehealth

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By Alpha Lillstrom

These days more providers, patients, and payers are evaluating the utility and benefits of using technology to support or provide health care services remotely. The use of telehealth is a significant and rapidly growing component of health care in the United States. Also known as telemedicine, the term encompasses everything from electronic visits, video technology, and remote monitoring to provide maintenance and preventive care for patients, to diagnosis and treatment when it is clinically appropriate. In some cases telehealth is used to provide access to care over distances that would otherwise present insurmountable obstacles to care. In other situations the technology improves convenience for both the provider and the patient. Over half of U.S. hospitals now use some form of telemedicine.1 In fiscal year 2013, more than 600,000 veterans accessed Veterans Affairs (VA) care using a telemedicine program—for a total of more than 1.7 million episodes of care.2 Even when effective mitigation of challenges is taken into account, reimbursement continues to present the most formidable obstacle.3 While your specific practice might not yet be delving into providing care using telemedicine, some are. Policy is evolving to make it more feasible and reimbursable.

Become a Veteran’s Choice Provider

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Expand your practice to better service your community.

By Alpha Lillstrom

It is an unfortunate reality that our veterans can experience delays in accessing care or wait unacceptably long periods for an appointment at a Veterans Administration (VA) facility or clinic. While progress has been made, many veterans are looking for better and more convenient ways to access the care they need. Thanks to much public outcry and two recent laws, a veteran who is enrolled in VA health care now has more choices. These laws enable private practice physical therapists to expand their businesses by enrolling as contract providers with the Veterans Health Administration (VHA).

The VHA is the United States’ largest integrated health care system with over 1,700 sites of care; it serves 8.76 million veterans each year.1 However, despite its size, it has been unable to meet the health care needs of veterans. In response to a nationwide scandal that emerged in 2014, the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act)2 was signed into law on August 7, 2014. This law established a Veterans Choice Program (Choice program) that will end on August 7, 2017—or earlier if the allocated funds are exhausted. The Choice program is separate from Tricare (the health care insurance program for retired members of the military and their families3) and Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.4 Instead, this is a temporary program with specific eligibility rules for those already enrolled in VA health care. This law allows a veteran to use a community-based provider if he or she has had to wait over 30 days for access to care. Under the Choice Act, geographic eligibility is based on whether the veteran lives over 40 miles from the closest VA facility; therefore, once the geographic test is met, an enrolled community-based provider can be utilized regardless of how close their office or clinic is to a VA facility or to the veteran’s home. This use of community-based providers, including physical therapists, is intended to address the two most glaring obstacles veterans face when trying to access necessary care.

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Although improvements were noted, delays persisted due to a lack of consistent guidelines and ineffective management. Moreover, thousands of veterans remained frustrated and confused by the new system. On July 31, 2015, a second law, the Veterans Choice Improvement Act (VCIA)5 was enacted to address lingering issues veterans experienced while attempting to access the care they were entitled to receive.6 The VCIA waives the previous 30-day wait requirement if care is clinically indicated. The law also improves the VA’s plan to consolidate community care by streamlining referrals and authorizations, as well as improving the process for providers in order to reduce the wait time between when care is provided and when the VA pays said providers. Additionally, in response to the reality of limited travel routes for veterans living in rural areas, this legislation modifies the distance factor used when determining who can utilize the Choice program—VCIA measures the distance a veteran lives from a VA site of care by 40 driving miles.

On December 1, 2015, in response to further criticism from veterans, members of Congress, and other stakeholders,7 the VA announced additional changes to the program. Under the updated parameters, a veteran is eligible for the Choice program if he or she is enrolled in the VA health care system and meets at least one of the following criteria8:

  1. told by his or her local VA medical facility that they will not be able to schedule an appointment for care within 30 days of the date the veteran’s physician determines he or she needs to be seen, or within 30 days of the date the veteran wishes to be seen if his or her physician did not specify a date;
  2. lives more than 40 miles driving distance from the closest VA medical facility with a full-time primary care physician;
  3. needs to travel by air, boat, or ferry to the VA medical facility closest to his or her home;
  4. faces an unusual or excessive burden in traveling to the closest VA medical facility based on geographic challenges, environmental factors, a medical condition, the nature or simplicity or frequency of the care needed, and whether an attendant is needed. The staff at the veteran’s local VA medical facility will work with the veteran to determine eligibility for any of these reasons; or
  5. lives in a state or territory without a full-service VA medical facility.9

Veterans Choice Program Mechanics

In the past, the Patient-Centered Community Care (PC3) has been the VA’s method of purchasing care for veterans from community-based providers. The Choice program supplements the existing PC3 by allowing coverage for even more services for eligible veterans while also providing veterans more flexibility in choosing whether to receive care in the community or through the VA. In order to be eligible for VA health care benefits and the Choice program, a veteran must have a service-connected disability, have served for a minimum length of time, and fall below a certain income level.

A veteran must initiate access to the Choice program by calling their third party administrator (TPA). The phone number is clearly listed on his or her Veterans Choice card. Before health care can be delivered through the Choice program, it must first be authorized by the regional TPA. There are two TPAs covering six PC3/Choice regions. Health Net is the TPA for half of the United States (regions 1, 2, and 4) while TriWest Healthcare Alliance covers regions 3, 5A, 5B (Hawaii), and 6 (Alaska).10 Preauthorization is required to ensure that the treatment in question is service connected. If a veteran is treated for a non-service-connected disability, that veteran may incur a fee for that care. While physical therapy is likely to be covered, not all services are.11

Enroll as a Veterans Choice Program Provider12

Before a physical therapist can provide care to a veteran through the Choice program, he or she must enroll as either a PC3 or Choice provider, but not both.13 Most PC3 providers are automatically eligible to participate in the Choice program. If you are interested in becoming a provider for the Choice program, you must first establish a contract with one of the TPAs—Health Net or TriWest—by calling 866-606-8198. Through contract, the TPA and Choice program providers establish an agreed-on amount for services, generally 100 percent Medicare reimbursement.14 Rates above 100 percent Medicare reimbursement may be negotiated for providers located in highly rural areas.15 However, it is important to note that PC3 contract reimbursement will be at a negotiated rate below 100 percent of Medicare.16 Therefore, while the Choice program is temporary, it could be worth the effort to become a Choice provider now and a PC3 provider later. If you are currently a Tricare provider with the Department of Defense, you will have to enroll separately as either a PC3 or Choice provider with the VA in order to participate in this program. The Veterans Choice program agreement is intentionally simple and less than three pages long. Once signed by the provider, it should be finalized by the TPA within two days.

The reimbursement process is also intended to be user friendly. First, one must complete an application form on the appropriate TPA’s website. On receiving the authorization package for the medical appointment from the TPA, providers can proceed with providing care to the veteran. After the appointment, providers must file a claim with the appropriate TPA. The VA is keen to maintain complete medical records; therefore, the TPA requires providers to also submit a copy of the records for medical care and services provided to the veteran.17 On successful processing, claims will be paid to the provider by the TPA.

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Provider eligibility

In order to be a PC3 or Choice provider, a therapist must be accessible to veterans and accept the payment rates outlined in the law as well as be in compliance with Medicare, federal, and state regulatory requirements. Additionally, a therapist must maintain at least the same or similar credentials as a VA facility. If care beyond what was originally authorized is necessary, a secondary authorization (SAR) is required. In the past, secondary authorizations were limited to 60 days per year; however, SARs are now based on an episode of care and can last up to a year. These SARs are granted by the TPA, not the VA.18

Program Assistance

In order to facilitate utilization of the program, the VA has provided a number of resources to both veterans and providers. There is a national Choice Program Call Center at 866-606-8198 that will verify eligibility and answer programmatic questions. Every VA medical center has a “Choice Champion” to help veterans and providers work with the program. In addition to the general program website,19 the VA also has a number of resources specifically created for providers that are available online.20

Conclusion

In order to address unacceptable delays and backlogs at VA hospitals and clinics, the Veterans Choice Program aims to provide veterans improved access to community-based care. By enrolling as a PC3 or Choice provider, private practice physical therapists can expand their practices to include caring for these veterans. Private Practice Section members evaluating their options should: (1) decide if participation in the Veterans Choice Program is beneficial or desirable for their practice; and, if so, (2) determine their preference of becoming a PC3 or Choice provider. On making this determination, those private practice physical therapists who enroll with their regional TPA as a provider will be ready to serve veterans in their own community-based clinics.

References

1. www1.va.gov/health/index.asp.

2. P.L. 113-146, www.congress.gov/113/plaws/publ146/PLAW-113publ146.pdf.

3. www.tricare.mil. Accessed February 2016.

4. www.va.gov/PURCHASEDCARE/programs/dependents/champva/champva_eligibility.asp. Accessed February 2016.

5. P.L. 114-41, www.congress.gov/114/plaws/publ41/PLAW-114publ41.pdf. Accessed February 2016.

6. www.gpo.gov/fdsys/pkg/BILLS-114hr3236enr/pdf/BILLS-114hr3236enr.pdf. Section 4005. Accessed February 2016.

7. The Veterans of Foreign Wars and other veterans advocacy groups kept a close eye on how the program was implemented and expressed concerns such as “35 percent of veterans who believed they were eligible for the program were offered the option to participate . . .there are still a number of hurdles that must be addressed if the Veterans Choice Program is to live up to its name.” www.military.com/daily-news/2015/09/28/veterans-find-va-choice-care-program-has-delays.html. Accessed February 2016.

8. www.blogs.va.gov/VAntage/24346/va-makes-changes-to-veterans-choice-program. Accessed February 2016.

9. This includes Alaska, Hawaii, and New Hampshire (but excludes New Hampshire veterans who live within 20 miles of the White River Junction VAMC) and the United States Territories (excluding Puerto Rico, which has a full-service VA medical facility). Accessed February 2016.

10. www.va.gov/opa/choiceact/documents/FactSheets/VACAA_Provider_Fact_Sheet_Choice_Program_508c_Internet.pdf. Accessed February 2016.

11. For example, there is a very limited benefit package for dental care, and emergency department visits are not covered. Accessed February 2016.

12. On Nov. 30, 2015, the VHA presented a webinar about the VCP and how practitioners may become providers for the program: www.raconline.org/topics/returning-soldier-and-veteran-health/veterans-choice-program-webinar.

13. www.triwest.com/en/vapc3-provider/Quick-Reference-Guides/VACAA-VAPC3-Differences_Network-Provider.pdf. Accessed February 2016.

14. www.ruralhealthinfo.org/topics/returning-soldier-and-veteran-health/pdf/veterans-choice-program-faqs.pdf Accessed February 2016.

15. Ibid.

16. Ibid.

17. TriWest can receive both documents by fax or electronic means. However, Health Net can only receive medical documentation by fax, but the claim can be received electronically. Accessed February 2016.

18. www.triwest.com/en/vapc3-provider/Find-a-Form/Secondary-Auth-Request.pdf. Accessed February 2016.

19. www.va.gov/opa/choiceact. Accessed February 2016.

20. www.va.gov/opa/toolkit/June2015_VCPToolkit_101ForPartners.pdf and www.va.gov/opa/choiceact/for_providers.asp. Accessed February 2016.

Lillstron

Alpha Lillstrom is a registered federal lobbyist working with Connolly Strategies & Initiatives, which has been retained by PPS. An attorney by training, she provides guidance to companies, nonprofit organizations, and political campaigns. For six years, she served as Senior Policy Advisor and Counsel for Health, Judiciary, and Education issues for Senator Jon Tester (Montana), advising and contributing to the development of the Affordable Care Act, as well as working on issues of election law, privacy, government transparency, and accountability. Alpha has also directed Voter Protection efforts for Senators Bob Casey, Al Franken, Russ Feingold, and Mark Begich. She was Senator Franken’s Policy Director during his first campaign and was hand-picked to be the Recount Director for his eventual 312-vote win in 2009.

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