Slow VA Choice authorization, reimbursements frustrate doctors' offices

Published: Mar. 22, 2016 at 8:09 PM EDT|Updated: Mar. 22, 2016 at 8:14 PM EDT
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SALISBURY, NC (WBTV) - Local doctors are having to stop accepting patients through a program designed to provide veterans with faster access to specialty care because of systemic problems within the program, an On Your Side investigation has found.

The VA Choice Program was created in 2014 following reports of some veterans waiting months or years for specialty care.

Under the program, a veteran who would have to wait more than 30 days to see a specialist can qualify to be treated by a private medical provider.

The VA Choice Program is administered by Health Net, a private company contracted by the VA.

Before veteran can actually receive treatment by a private medical provider, Health Net must authorize the treatment.

Lots of time on hold, few treatments authorized

Many doctors' offices say they began experiencing problems with Health Net and the Choice Program before their treatments even began.

"Health Net would call for the appointment, which we would make," explained Sandra Jarrett, the practice manager of Salisbury Orthopedic. "We'd start checking a week or two before the appointment and they would either tell us it hadn't been authorized of they would tell us it had been faxed but we didn't have it."

The constant mix-ups meant staff had to spend more time on the phone trying to get patients' authorizations straightened out, Jarrett said.

It was not unusual for staff at Salisbury Orthopedic to spend up to three hours waiting on hold to speak with a Health Net representative to track down missing paperwork.

"We would fax in the request for additional services and it would take weeks. We would start calling, we were on hold again; sometimes we'd get cut off. Anyone you'd talk to, they wouldn't give us a last name. We couldn't call back to check with the same person. They couldn't see it in the system; the faxes were not being connected with the patient," Jarrett said.

As a result, Jarrett said, they would have to continually cancel and re-schedule appointments for their VA Choice patients.

"The patient would get very frustrated with us," Jarrett said. "We want to help the veterans, we really do, but it got to be very frustrating."

On top of that, Jarrett said, when they did hear from Health Net, the company would often send documents intended for other medical providers.

"We got faxes for authorizations for doctors in Michigan. Other doctors from around the state would call us and say 'we got your fax for an authorization for a patient' and it went to them," Jarrett recalled.

Jarrett said the delays likely stemmed from a system that still relies entirely on human staff receiving a paper fax and connecting it with a patient's file; outdated technology to keep track of an every-growing program that's not keeping pace with 21 century technology.

"I think that Health Net needs to fix their disconnect within their system," Jarrett said. "They've got to figure out some way where these authorizations can be sent electronically and be matched at the same time with that veteran."

As a result, patients were being authorized for a surgery but not the physical therapy required for afterward, Jarrett said, which meant doctors at her practice would not be willing to do the surgery.

Salisbury Orthopedic has stopped accepting new VA Choice patients until they can clear the backlog of patients currently in their system.

Health Net slow to pay for treatment

Even after a veteran's treatment is authorized through the VA Choice Program, an On Your Side investigation has found that the doctor who provided the treatment may never get paid.

Our questions for Health Net began in February after Marine veteran Jim Bancroft was told by his neurologist that he could not treat him for an additional problem.

Like Salisbury Orthopedic, Bancroft's doctor, Carolina NeuroSurgery & Spine Associates, had stopped accepting new patients or treating existing patients for new issues.

In a statement provided in February, a spokeswoman for Bancroft's doctor said the decision was necessary because Health Net was not providing timely reimbursement for the VA Choice patients.

Jarrett, at Salisbury Orthopedic, said her practice has had similar luck getting paid.

"We haven't been paid for any of our surgeries (since July 2015)," she said. "We've been paid for some of the office visits but haven't been paid for the surgeries."

Jarrett said she recently spoke with a practice in Raleigh that was waiting to be paid $200,000 for surgeries that had been authorized and performed on VA Choice patients.

"Health Net shouldn't have taken this contract if they didn't have the staff, the means and the technology to handle it," Jarrett said. 'And the VA probably shouldn't have hired them without vetting them to see if they could handle the situation."

Problems across the state

The authorization and reimbursement problems local practices have experienced with Health Net and the VA Choice Program have been felt at medical practices across the state.

Bob Seligson, CEO of the North Carolina Medical Society, said his organization has been working to find a solution that will allow practices to continue treating veterans through the Choice Program.

"It's the thing to do as an American' it's the thing to do to help our veterans so we want to make sure the program's working and do what we can to address the issues that our doctors are encountering," Seligson said.

But Seligson said there's no telling how long it will take to find a solution that actually fixes the problem.

"We didn't realize the magnitude of (the problem) until we started checking around and we've had at least thirty practices call in across the state about these issues," Seligson said. "The Veterans Choice Program has been plagued by administrative problems."

Seligson said he and his group have been working with Health Net and with North Carolina's congressional delegation to address the problem.

Earlier this month, Senator Richard Burr (R-NC) led a group of senators in introducing new legislation that seeks to fix problems with the VA Choice Program.

In testimony before the Senate Veterans Affairs Committee about the legislation last week, Burr cited a story by On Your Side Investigates that first uncovered problems last month.

At that committee meeting, senators from both parties seemed to be resolved to work together to find compromises that would allow the committee to put forth comprehensive legislation to address a range of VA problems, including Burr's legislation to fix the VA Choice Program.

Health Net responds

In respond to a request for comment from On Your Side Investigates, a Health Net spokesman offered the following statement:

"Since the inception of the Veterans Choice program in late 2014, Health Net has scheduled over 400,000 medical appointments for veterans; answered more than 2.5 million phone calls from veterans, health care providers and Veterans Affairs staff to help coordinate veterans' care; and we have contracted with more than 125,000 health care providers (with another 240,000 ready to contract with us, if called upon)."

"To accommodate the month-over-month growth in the program, and assist veterans in obtaining their needed care, we recently opened a new service center – and we expanded our existing centers. With is this expansion, we have approximately 2,400 associates supporting the Veterans Choice program, many of whom are veterans themselves."

"Developing a complex and consistent new program like Veterans Choice is a team effort, and Health Net is working closely with Congress, the Department of Veterans Affairs, health care providers and many others to provide veterans with the appropriate, coordinated and convenient care they have earned for their service."

"As we rapidly expand our operations and services to meet the demand of veterans, there may be situations where a veteran does not get care as expeditiously as we would like. In the event a veteran does not receive timely access to care under the Veterans Choice program, he or she may call Health Net's Veterans Choice Customer Service area at 866-606-8198."

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