Wiki Questions regarding Medicare billing secondary to VA (for inpatient Medicare Part A claims)

[kkabramson]

Hello, all!

I've been tasked with researching four questions related to Inpatient Part A claims where patient has either VA & traditional Medicare Part A, or VA and Medicare HMO/Medicare Advantage. I have limited experience with VA, so any input you can offer is appreciated. Thank you!

1) Determine whether there is a way to know if a claim should be billed to Medicare Part A secondary to VA.

2) Does it have to be done for Medicare DSH compliance?

3) Will it always generate an IME payment for a teaching hospital?

4) Should it be done for GME and NAHE even if it will not generate an IME payment?

 

[vanessamoldovan]

Hello, all!

I've been tasked with researching four questions related to Inpatient Part A claims where patient has either VA & traditional Medicare Part A, or VA and Medicare HMO/Medicare Advantage. I have limited experience with VA, so any input you can offer is appreciated. Thank you!

1) Determine whether there is a way to know if a claim should be billed to Medicare Part A secondary to VA.

2) Does it have to be done for Medicare DSH compliance?

3) Will it always generate an IME payment for a teaching hospital?

4) Should it be done for GME and NAHE even if it will not generate an IME payment?

Hello, Mary Wood with NAB would like to help you with this response, but she is unable to get into the forums. Can you please reach out to her at pinkcode51@gmail.com? She'll be more than happy to help. Vanessa

 

[Williford33]

Inpatient Part A claims can only be billed to VA as primary through one of their third party administrators (Triwest or Optum depending on date and region) if a notification was made to the Va within 72 hours of ER presentation or transfer from outside hospital. Or well prior to services for elective or routine inpatient care. Elective inpatient must be coordinated by the VA who authorizes Triwest or Optum to pay. If VA authorizes the care episode then VA sends auth to either Triwest or Optum as primary and only payer. Provider bills Triwest or Optum and payment is payment in full- there is no patient liability. So if care was authorized it goes to Triwest or Optum only. If no authorization was obtained and it is an urgent or emergency admission or direct admit VA office of community care can be billed with medical records and depending on the veterans service condition the claim may be paid directly by VA in the Millennium Bill Program 1725 or the Unauthorized Care Program 1728. But before biling an unauthorized claim you want to contact VA to check the patient's VA COB file. Depending on VA COB and veterans service condition they may tell you that Medicare A or other health insurance is primary for that encounter and you'd bill them first. VA may decide this after the claim is filed and processed as well. Make sure you don't miss a Medicare timely filing deadline as Va clean claims can take 6 months to finalize.
If you do end up billing Medicare AB or OHI primary, you can bill Va as secondary payer on ER and Er to inpatient claims (not elective) per the Wolfe v Wilke decision of October 2019. Va will pay on deductible and coinsurance amounts but not copays. VA billing takes a dedicated and knowledgeable person in charge who knows military payers in and out. Hope this helps you. Any questions let me know! Lisalhooq@gmail.com

 

[kkabramson]

Inpatient Part A claims can only be billed to VA as primary through one of their third party administrators (Triwest or Optum depending on date and region) if a notification was made to the Va within 72 hours of ER presentation or transfer from outside hospital. Or well prior to services for elective or routine inpatient care. Elective inpatient must be coordinated by the VA who authorizes Triwest or Optum to pay. If VA authorizes the care episode then VA sends auth to either Triwest or Optum as primary and only payer. Provider bills Triwest or Optum and payment is payment in full- there is no patient liability. So if care was authorized it goes to Triwest or Optum only. If no authorization was obtained and it is an urgent or emergency admission or direct admit VA office of community care can be billed with medical records and depending on the veterans service condition the claim may be paid directly by VA in the Millennium Bill Program 1725 or the Unauthorized Care Program 1728. But before biling an unauthorized claim you want to contact VA to check the patient's VA COB file. Depending on VA COB and veterans service condition they may tell you that Medicare A or other health insurance is primary for that encounter and you'd bill them first. VA may decide this after the claim is filed and processed as well. Make sure you don't miss a Medicare timely filing deadline as Va clean claims can take 6 months to finalize.
If you do end up billing Medicare AB or OHI primary, you can bill Va as secondary payer on ER and Er to inpatient claims (not elective) per the Wolfe v Wilke decision of October 2019. Va will pay on deductible and coinsurance amounts but not copays. VA billing takes a dedicated and knowledgeable person in charge who knows military payers in and out. Hope this helps you. Any questions let me know! Lisalhooq@gmail.com

Thank you so much for your reply! This is exactly what I was looking for. I'd found some of this information from my own research but you filled in some important holes.