VA Patient-Centered Community Care and Veterans Choice Program: Worth it for Providers?

August 23rd, 2017 - Jared Staheli

Categories: Insurance Gastroenterology

As the opportunities for providers outside the VA system expand in order to meet demand, you may be interested in offering services to veterans and the VA, if you are not already. With overwhelming bipartisan support, the opportunities are not likely to abate, but are those opportunities worth it for you?

First, it is important to understand the differences between Patient-Centered Community Care (PC3) and the Veterans Choice Program (VCP). While both use outside providers to care for veterans with the goal of reducing wait times and/or increasing accessibility, the mechanism for doing so is different. PC3 works by referring veterans out to providers who have contracted with TriWest or Health Net (VA administrators). The VCP, on the other hand, starts with the veteran contacting TriWest or Health Net with a request to see the physician of their choice. VCP providers do not sign a contract with TriWest/Health Net as they would if they were a PC3 provider.

Though they are separate programs, the VA considers the VCP supplementary to PC3 and is working on plans to consolidate the way the programs work. As it stands now, PC3 providers are automatically qualified to participate in the VCP, but not the other way around.

When deciding whether participation is worth it, there are a few points to consider:

Reimbursement rates for these programs are equivalent to Medicare rates. It is true that Medicare rates are typically lower than the rates of private insurance carriers, but like Medicare, these lower rates come in exchange for a larger potential pool of clients.
The VA considers it important that providers have a basic understanding of military culture and the unique problems veterans face. If you are going to participate, the VA offers some basic training modules for providers. Because in many instances, even with the VCP, the contractor chooses the provider the veteran is sent to, it is important that you exhibit competency in this regard if you want to work with these patients. Click here for a VA fact sheet on this topic.
Because this is a new program (PC3 began in 2013 and VCP in 2014), and there are plans for reform and consolidation, there will likely be many changes over the coming years. Though there will certainly be efforts made to limit the effect on physicians as the programs are in flux, you may be required to spend additional time and effort keeping up to date and in compliance.

However, if you want to participate, the first step is contacting the appropriate contractor. Click here to see which contractor has jurisdiction over your location.

For more provider information, click here to see the Provider Toolkit page from the VA, which includes handbooks from Health Net and TriWest.

###

Questions, comments?

If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.

Latest articles: (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.

The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox

Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.

Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period?

Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox

Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.