Become a Veteran’s Choice Provider
Expand your practice to better service your community.
By Alpha Lillstrom
April 4, 2016
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.
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:
- 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;
- lives more than 40 miles driving distance from the closest VA medical facility with a full-time primary care physician;
- needs to travel by air, boat, or ferry to the VA medical facility closest to his or her home;
- 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
- 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.
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
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
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.
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.
14. www.ruralhealthinfo.org/topics/returning-soldier-and-veteran-health/pdf/veterans-choice-program-faqs.pdf Accessed February 2016.
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.
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.