VA to implement new electronic claims processing system

As part of its new Community Care Program, the Department of Veterans Affairs will require non-VA healthcare providers to submit electronic claims through a new claims processing system.

The system, which will be deployed in 2019, is part of the VA’s efforts to move away from paper claims and to address the timeliness and accuracy of payments to community care providers.

“We must ensure community providers are paid in a timely manner so they are willing and able to deliver services to our veterans,” testified VA Secretary Robert Wilkie on Wednesday before a joint Senate-House hearing. “This automated electronic Claims Administration and Management System (e-CAMS) uses technology with workflow-based analytics to provide feedback on potential bottlenecks and business performance issues in our claims process.”

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Robert Wilkie, secretary of Veterans Affairs (VA) nominee for U.S. President Donald Trump, speaks during a confirmation hearing before the Senate Veterans' Affairs Committee on Capitol Hill, in Washington, D.C., U.S., on Wednesday, June 27, 2018. The VA has lacked a permanent leader since David Shulkin was ousted as secretary in March and Rear Admiral Ronny Jackson withdrew in April, following allegations of improper behavior in his role as White House physician. Photographer: Al Drago/Bloomberg

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In his testimony, Wilkie said that community providers will have 180 days to submit claims for reimbursement—rather than waiting years to submit them—thereby aligning the VA with industry standards and ensuring providers receive timely payments.

“This will put the Department of Veterans Affairs in line with the most modern healthcare administrations in the country,” he observed.

Steven Lieberman, MD, executive in charge of the Veterans Health Administration, told lawmakers that by requiring providers to submit electronic claims—except in rare circumstances—it will “speed up” the process.

“We also will have an off-the-shelf product that will auto-adjudicate the claims and pay them in a timely manner,” noted Lieberman.

The agency “has an IT problem,” Wilkie acknowledged. “When it comes to claims processing, hands have to touch each claim. What we have done is look to the market for off-the-shelf technology that will allow us to automate the claims process.”

The VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018, which was signed into law by President Trump in June, is meant to streamline the VA’s community care programs and enable veterans to receive care from community providers.

The MISSION Act requires access to community care if: VA does not offer the care or services the veteran requires; the agency does not operate a full-service medical facility in the state a veteran resides; the veteran was eligible for care in the community under the 40-mile rule in the Veterans Choice Program and meets certain other criteria; VA is not able to furnish care within the designated access standards established by the agency; or a veteran and the veteran’s referring clinician agree that furnishing care or services in the community would be in the best medical interest of the veteran.

Wilkie said that under the MISSION Act the agency has established a Center for Innovation for Care and Payment to come up with new approaches to testing payment and service delivery models for incentivizing performance internally and when VA purchases care in the community.

“The center has developed a charter and is developing criteria for pilot projects to drive healthcare quality and efficiency,” he added.

A provision of the MISSION Act also requires the VA to implement a process to ensure that community providers have access to available and relevant patient medical histories, such as a list of all prescribed medications.

The law mandates that “contracted providers submit medical records of any care or services furnished, including records of any prescriptions for opioids, to VA in a timeframe and format specified by VA” and that the “VA would be responsible for recording those prescriptions in the electronic health record.”

A major challenge for the agency is increasing access to care and benefits through the MISSION Act implementation and business transformation, which includes adopting a new Cerner electronic health record system, according to Wilkie.

Both the VA and Department of Defense will implement Cerner’s Millennium EHR platform in an attempt to achieve full VA-DoD interoperability. In addition, the agency is working to achieve interoperability with community providers.

The goal of the latter is to ensure that “we communicate with doctors in the private sector, community care hospitals, as well as private pharmacies—and to talk to those systems that are not part of the Cerner network,” commented Wilkie.

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