Sample Authorization Letter of Release the Authenticated Letter

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					Health Information Management
 and Non-VA Purchased Care
          Janet Wilson
         August 9, 2010
           809_HIM_2


                            1
Non-VA Purchased Care Programs

• Fee Basis
   – Authorized care
• Mill Bill
   – Emergency Care / Unauthorized
   – VISNs 20 and 22 (FSC Pilot)
• Contract Care
   – Contracts
   – Project HERO (VISNs 8, 16, 20, 23)
   – National Dialysis Project

       7/28/2011                          2
        What Purchased Care is
              and is Not
       Purchased Care is                       Purchased Care is Not
Supplement to VA health care              Substitute or replacement for VA
                                          health care
Secondary care when service is            Primary care
not available within the VA
   - Limitations to extend care may
     be authorized
Health care delivery system               Insurance or a health plan
   - Requires matching of claims to       - No standard set of benefits
     individual authorizations for care
Flexible, can adapt Medicare              Medicare or TRICARE
payment rules for certain types of
claims

             Augmentation of in-house capabilities and capacity
                                                                             3
             Examples Non-VA Provided
                    Fee Care
Types of programs supported vary from station to station
Fee Medical                              State Veteran Nursing Homes with Free Drug
                                         Program
Fee Dental                               State Veterans Domiciliaries
Contract Hospital [inpatient]            State Veterans Hospitals
Unauthorized Outpatient                  State Veterans Adult Daycare

Millennium Bill Emergent Care Dialysis   Contract Nursing Homes

Radiation Therapy
Fee Pharmacy/Prescription                Contract Adult Day Health Care
Comp and Pension                         Respite Care
Organ Transplants                        Homemaker/home Health Aide
Fee Travel/Fee Ambulance                 Home Care [skilled, IV therapy, wound care, etc.]

Infertility and Reproduction/Fee         Hospice [home and inpatient]
Obstetrics
Chiropractic                             Appeals [Clinical, reconsiderations and BVA]


                                                                                             4
                 Fee Legislative
                  Authorities
38 U.S.C 1703   Obtaining Non-VA inpatient and outpatient medical
                services on a preauthorized basis by contract or
                individual authorization

38 U.S.C 1725   Reimbursement for emergency treatment of Non-
                service connected conditions in a Non-VA facility
                without prior authorization

38 U.S.C 1728   Reimbursement for emergency treatment of service-
                connected or related conditions in a Non-VA facility
                without prior authorization

38 USC 8153     Sharing health care resources with Non-DoD health
                care providers, or other entities



                                                                       5
            Fee Claims Pricing
               Schedules
38 CFR Regulates hospital and professional medical care
       claims pricing

17.55     Hospital inpatient use of facility care
             – Center for Medicare and Medicaid Services Acute
             Care Inpatient Prospective Payment System (IPPS)
             – Acute Care IPPS Exempt
             – Per Diem based on extent of authorization

17.56     Physician and Outpatient use of facility care
             – CMS Resource Based Relative

17.1005 “Mill Bill” payer of last resort pricing


                                                                 6
 Fee Basis Claim System Software

• Class I software
• National implementation of software in
  November 2009
• All VISNs except:
  – VISN 6 (3M Pilot)
  – VISN 11 (Health Care Claim Processing Pilot
    with Financial Service Center)



                                                  7
Authorized and Unauthorized Non-VA Care
• Authorized Care
  – Non-VA Care or treatment approved in advance
  – Does not require medical documentation be
    submitted to VA prior to payment
• Unauthorized Care
  – Non-VA Emergency Care or treatment not
    approved by VA prior to the care or treatment
    being provided to the Veteran
  – Requires medical documentation be submitted to
    VA prior to payment
  – No longer requires validation prior to payment

                                                     8
Justification of Non-VA Referral

• Nationally developed Referral template
• Required documentation
  – VA facility does not provide the required service
  – Veteran cannot safely travel to VA facility due to
    medical reason (specify medical reason)
  – Veteran cannot travel to VA facility due to
    geographical inaccessibility
  – VA facility cannot provide the required service
    timely
  – Other (please specify)

                                                         9
  Health Information Managements Roles and
                  Responsibilities


Fact Sheets for Non-VA Purchased Care
• Validating and Recording Coded Data
  – Recording data for both inpatient and outpatient
    encounters
• VistA Imaging Capture
  – All Non-VA Purchased Care documentation
    should be retained
• Release of Information
  – Accounting of disclosure

                                                       10
Validating and Recording
       Coded Data




                           11
  Validating and Recording Coded
                Data
• Inpatient
  – Admission
  – Census
  – Observation
• Outpatient
  – Office visits
  – Emergency room
• Retrospective Audits
  – Sample size determined by facility workload

                                                  12
                   Inpatient

• Non-VA Patient Treatment File (PTF)
  generated automatically
• Exception: Mill Bill claims for those facilities
  participating in the Mill Bill and FSC Pilot
  – Mill Bill Non-VA PTF’s must be created manually
    using “Set-up a Non-VA PTF Record” option
  – VISN 20 and VISN 22
• Monthly reconciliation between Fee Basis
  Inpatients and Non-VA PTF’s recommended

                                                      13
                 Inpatient

• Same guidelines apply to Non-VA PTF as
  a regular PTF
  – Exception:
    • Non-VA PTF may be completed and transmitted to
      Austin for up to 7 years from discharge date.
• Allocation Resource Center (ARC) uses
  both the Non-VA PTF and Fee Paid files
  for workload credit


                                                  14
              Non-VA PTF

• Unlike a regular VA PTF, not all
  information auto-populates to the Non-VA
  PTF
  – Source of admission
  – Date and time of discharge
  – Discharge status
  – Discharge/treating specialty
  – Bed section codes
  – Source of payment
  – Type of disposition
                                             15
              Non-VA PTF

• For complete instructions on Non-VA
  PTF’s:
  – Patient Treatment File Training Guide, March
    2009
  – DS non-VA PTF Hospitalization.doc




                                              16
               Non-VA PTF

• Patient refuses to return to VA for care
  after stabilization
  – Patient is discharged from VA Fee Basis rolls
  – Total number of days of care are recorded in
    Non-VA PTF
     • Discharge date in Non-VA PTF may differ from
       the date Fee Basis stops payment of the
       hospitalization




                                               17
               Non-VA PTF

• How do I know when a Non-VA PTF
  needs to be completed?
  – Work with your local Fee Department
    • FBCS reports available
    • Mill Bill / FSC Pilot
    • Copies of claims
  – VSSC Webiste
  – Open PTF Record Listing
    • Provides a listing of PTF records in an open status
      for discharged patients

                                                   18
       Non-VA PTF Census

• Census must be completed on non-VA
  PTF
  – VHA Directive 2007-030, Closeout of
    Veterans Health Administration Corporate
    Patient Data Files Including Quarterly
    Inpatient Census
• “Fee Basis Census Status Report” Option
• Fee Departments and HIM should work
  closely together in order to complete
  Quarterly Census of Non-VA PTF records

                                               19
        Observation Stays

• Do not enter as a Non-VA PTF
• Outpatient not Inpatient




                                 20
 Outpatient and Emergency Room

• Should not be entered into Patient Care
  Encounter (PCE) or Event Capture
  – Only non-count clinics if entered
• Information is transmitted to Austin via the
  VistA Fee software package
  – Duplicate workload if entered into PCE or
    Event Capture count clinics



                                                21
        Retrospective Reviews
• Non-VA Purchased Care no longer required to be
  validated by HIM prior to payment of the non-VA claim
  (inpatient or outpatient)
• Periodic retrospective reviews performed on coding of
  non-VA claims
 Sample size determined by facility workload
• Medical documentation must support non-VA claim
  submitted
• Coding errors/differences should be returned to the
  Fee Office
• Trends should be reported back to the external
  providers
• HIM and Fee should work together to educate the
  external provider

                                                    22
     Non-VA PTF References

• VHA Handbook 1907.03
• VHA Handbook 1907.04
• Patient Treatment File (PTF) Training
  Guide, March 2009
• DS Non-VA PTF Hospitalization




                                          23
VistA Imaging Capture




                        24
       Why do we have to keep
          EVERYTHING?
Retention Requirements
• All administrative and clinical information
  must be maintained
  – Veteran may appeal any decision
  – Up to 1 year after the denial
  – Non-VA DRG Recovery Audit
• Non-VA Purchased Care claims should
  not be retained in the patient health record

                                                25
        VistA Imaging Capture

• Fee Basis Claim System (FBCS)
  – Document Manager
    •   Fee - Inpatient
    •   Fee - Outpatient
    •   Fee - Emergency
    •   Fee - Miscellaneous
  – Import into VistA Imaging
    • Import / Index appropriately
• VistA Imaging

                                     26
        VistA Imaging Capture

• Non-VA Claims that must be received with
  associated documentation
  – Unauthorized Claims
     • Emergency room
     • Inpatient admission
  – Mill Bill
     • Emergency room
     • Inpatient admission
  – Contract (Civil) Hospital
     • Inpatient Admission


                                      27
                     Inpatient
• ORIGIN: FEE
• DOCUMENT IMAGE DATE: Date of discharge
• DOCUMENT IMAGE TYPE: MEDICAL RECORD
• SPECIALTY: Choose the specialty of the clinician,
  NOT the ward (Sometimes due to overflow a surgery
  patient is placed on a medicine floor but he is a
  SURGERY patient not a medicine patient. A medicine
  floor might have a mix of patients such as Cardiology,
  Pulmonary, Neurology, and
  Medicine.)
• PROCEDURE/EVENT: INPATIENT STAY
• IMAGE DESCRIPTION: Type in the hospital name for
  the inpatient stay
                                                     28
           Ambulatory Surgery
• ORIGIN: FEE
• DOCUMENT IMAGE DATE: Date of procedure
• DOCUMENT IMAGE TYPE: PROCEDURE
  RECORD/REPORT
• SPECIALTY: Choose the specialty of the clinician
  performing the surgery
• PROCEDURE/EVENT: Choose the appropriate
  procedure/event for the specialty selected from the drop
  down menu in VistA Imaging
• IMAGE DESCRIPTION: Type in the facility’s name that
  performed the ambulatory surgery

                                                        29
 Anatomical, Surgical and Cytology
             Pathology
• ORIGIN: FEE
• DOCUMENT IMAGE DATE: Date specimen was taken
• DOCUMENT IMAGE TYPE: PROCEDURE
  RECORD/REPORT
• SPECIALTY: LABORATORY
• PROCEDURE/EVENT: REFERENCE LAB
• IMAGE DESCRIPTION: Type in the facility’s name,
  address, accrediting organization, and CLIA number that
  performed the laboratory procedure and the name of the
  specimen (body part, blood, etc.). NOTE: The image
  description field is limited to 60 characters. Additional
  information can be entered in the image long description
  if needed.
                                                       30
              Mammography
• ORIGIN: FEE
• DOCUMENT IMAGE DATE: Date of mammography
• DOCUMENT IMAGE TYPE: PROCEDURE
  RECORD/REPORT
• SPECIALTY: RADIOLOGY or OBSTETRICS &
  GYNECOLOGY
• PROCEDURE/EVENT: MAMMOGRAPHY
• IMAGE DESCRIPTION: Type in the facility’s name that
  performed the procedure and the name of the procedure




                                                    31
                    Radiology
• ORIGIN: FEE
• DOCUMENT IMAGE DATE: Date of procedure
• DOCUMENT IMAGE TYPE: PROCEDURE
  RECORD/REPORT
• SPECIALTY: RADIOLOGY or NUCLEAR
  MEDICINE
• PROCEDURE/EVENT: Choose the appropriate
  procedure/event for the specialty selected from the drop
  down menu in VistA Imaging
• IMAGE DESCRIPTION: Type in the facility’s name that
  performed the procedure and the name of the procedure

                                                        32
               Administrative

•   Attach to the Patient Only (Administrative)
•   ORIGIN: FEE
•   DOCUMENT IMAGE DATE: Date of service
•   DOCUMENT IMAGE TYPE: DENIAL LETTER
•   IMAGE DESCRIPTION: Type in the facility’s
    name that performed the service




                                                  33
          Administrative (cont.)

•   Attach to the Patient Only (Administrative)
•   ORIGIN: FEE
•   DOCUMENT IMAGE DATE: Date of service
•   DOCUMENT IMAGE TYPE: Correspondence
•   IMAGE DESCRIPTION: Authorization for Care,
    Appeal rights, etc…




                                                  34
                Timeliness

• DocManager
  – 180 days
  – Import into VistA Imaging within 5 business
    days of receipt




                                                  35
             Authentication

• All documents must be authenticated
  – Educate fee clerks to ensure they understand
    what constitutes an authenticated document
• Summary Progress Note




                                              36
Indexing Quick Reference




                 37
Release of Information
    Requirements




                         38
           Release of Information
               Requirements
• Fee Basis
  – May disclose individually-identifiable health
    information excluding 38 U.S.C 7332 –
    protected information, to a non-VA health care
    provider without prior written authorization for
    treatment and health care referrals
     •   Non-VA health care provider
     •   Resident care homes
     •   Assisted living facility
     •   Home health
  – Accounting of disclosure required

                                                  39
          Release of Information
          Requirements (Cont.)
• Mill Bill
   – May disclose individually-identifiable health
     information excluding 38 U.S.C 7332 –
     protected information, to a non-VA health care
     provider caring for an individual under
     emergent conditions.
   – Notification of disclosure must be mailed to
     patient
   – Accounting of disclosure required


                                                      40
        Release of Information
        Requirements (Cont.)
• Contract Care
  – VHA may disclose or release individually-
    identifiable information, including 38 U.S.C.
    7332 protected information, to VA contractors
    for the purpose of the contractor performing a
    service under the contract related to VA
    treatment, payment, and/or health care
    operations without the written authorization of
    the individual, as long as the disclosure is
    within the scope of the contract.
  – Accounting of disclosure is not required

                                                  41
          Release of Information
          Requirements (Cont.)
• Releasing information from Non-VA
  Purchased Care providers
  – Considered part of the VHA record
  – Subject to the disclosure provisions
    •   Privacy Act
    •   HIPAA
    •   Privacy Rule
    •   FOIA
  – Process under VHA and local policies

                                           42
     Accounting of Disclosure

• Required for Fee Basis and Mill Bill
• Not required for Contract Care (including
  Project HERO and Dialysis)
• Disclosure Tracking
  – ROI Software
  – Manual Spreadsheet




                                              43
Privacy Quick Reference




                44
          Fee Basis Example

• Veteran X has been approved for non-VA
  Purchased Care (Fee Basis) treatment of his
  chronic renal failure and Mr. X calls the Fee
  Basis clerk and informs him of the provider that
  he wishes to provide his care outside of the VA.
  The Fee Basis clerk copies the pertinent health
  information and mails it to the provider prior to
  Mr. X’s scheduled appointment.




                                                  45
           Fee Basis Example
• Veteran X has been approved for Non-VA purchased
  care (Fee Basis) treatment of AIDS. Mr. X calls the Fee
  Basis clerk and informs him of the provider that he
  wishes to provide his fee basis care. Because the health
  care being provided pertains to information protected
  under Title 38 U.S.C. Section 7332, the Fee Basis clerk
  mails Mr. X an authorization form approving the release
  of the protected information. Upon receipt of the
  patient’s valid authorization, the Fee Basis clerk copies
  the pertinent health information and mails it to the
  provider prior to Mr. X’s scheduled appointment.



                                                         46
       Contract Care Example

• Veteran X has been scheduled an appointment
  with a provider that has been contracted with his
  local VAMC under Project HERO. Mr. X was
  given a copy of his health record prior to his
  appointment. Upon arriving at the scheduled
  appointment, Mr. X realizes that he has forgotten
  the copies of his health record. The Project
  HERO provider contacts Mr. X’s local VAMC and
  requests copies of his health record in order to
  provide the care requested.

                                                47
   Non-VA Purchased Care Fact
            Sheets
• Validating and Recording Coded Data for
  Non-VA Purchased Care (Updated March
  2010)
• Non-VA Purchased Care – Release of
  Information Requirements (March 2010)
• Non-VA Purchased Care – VistA Imaging
  Capture (May 2010)



                                        48
49
HIM Non-VA Purchased Care
         Contact




  Email: Janet.Wilson@va.gov
  Phone: (828) 200-1520




                               50

				
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Description: Sample Authorization Letter of Release the Authenticated Letter document sample