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Thread: Billing Guidelines for the VA

  1. #1
    Join Date
    Apr 2007
    Tucson, AZ

    Default Billing Guidelines for the VA

    AAPC: Back to School
    Does anyone have some good resources for billing patients who are covered by the VA when they are seen outside of VA facilities? My doctors (inf. dis. specialists) who see VA patients rarely get paid, but the remittances are not clear about whether or not the patient can be billed for those services.

    For example, on a recent office visit, the remark code stated that "Veteran was not pre-approved for outpatient services by the Dept of Veterans Affairs." Some payers hold patients responsible for getting services preauthorized, but does the VA? Or is this supposed to be the provider's responsibility/write-off?

    On hospital visits, we often get this one: "A VA Medical facility was readily available in the patient's geographic area and capable of furnish (sic) economical care." If the patient chooses to come to the local hospital instead of going to the VA facility, can the patient be billed for those charges, or is the provider supposed to write those off? We have had some claims where the VA requested complete medical records before deciding that the patient had not been sick enough to warrant emergent treatment in the local hospital, but again, they don't state who is financially responsible for the charges that were incurred.

    Every single remittance contains the following statement: "Payment by VA constitutes payment in full. The veteran may not be billed for any services covered by VA's authorization." There are no phone numbers on these remittances to call with questions, and trying to find answers on the VA website is next to impossible.

    Can anyone explain this program to me? And in the immortal words of Denzel Washington in the movie Philadelphia, "explain it to me like I'm a six-year-old."

    Kathy Burke, CPC
    HealthCare Billing Resources

  2. #2


    All va care has to be prior authorized by the va prior to giving treatment.
    The va has to coordinate all of the patients care and will only give a prior auth to an outside provider when there are no resources available at the patients local va facility.
    If the patient is hospitalized for emergency care, a prior auth is not required and the va will pay once they deem that the services were for emergency care.
    That being said, if the patient chose to go outside the va for non emergent care and did not have the proper referral/prior auth to an outside provider then the patient is responsible for the bill.
    The va will pay claims with an authorization, or for emergency care.
    The va however will not pay claims as a secondary to another federal insurance such as medicare. In fact it is illegal to seek payment from va after medicare has paid, which means the patient balance deemed by medicare is patient responsibility.
    Hope this helps

  3. #3
    Join Date
    Apr 2007
    Tucson, AZ


    Yes, that does help a lot--thank you! Now I just need to convince the practice that they HAVE to get an authorization if they want to see the patient for a follow-up visit from their hospital stays.

    Would you recommend sending notes with the initial claims if you suspect that it was emergent care, or is it better to wait for the VA to request them? They seem to take a long time to make that all-important emergency determination, and if sending the notes with the claim will speed that up, I'll give it a try.

    Also, is there a definitive way to know if the patient should be held responsible if the VA ultimately determines that a hospitalization was not emergent in their opinion? It's not clear to me from their EOBs when or if the patient can ever be billed.

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