A Guide To VA Authorizations, Billing, and Reimbursement (2024)

Home care agencies who are unfamiliar with the VA referral and authorization process might find it difficult to navigate these confusing waters.

Whether you are a home care provider who is new to working with Veterans, or an experienced provider who is looking to improve your understanding of the VA system, this guide will provide you with the information you need to navigate the VA referral and reimbursement process with confidence.

Rates And Reimbursement

How Much Does The VA Pay For In-Home Care?

Perhaps your biggest question surrounds rates and reimbursement. The VA has very attractive rates in many areas.

The rates change at the beginning of each year, so it is important to keep up to date. You can find your rates directly on the VA's website, or by using our simple tool that lets you find rates by entering a zip code, city, or state.

View your local reimbursement rates

The VA's payment rates for home care services depend on the type of care being provided and the location of the care.

Referrals And Authorizations

How Do Referrals From The VA Work?

A Guide To VA Authorizations, Billing, and Reimbursement (1)

If you are not yet part of the Community Care Network, take a look at our article on getting credentialed with Optum and Triwest for more information.

Optum and TriWest are two Third-Party Administrators that work with the Department of Veterans Affairs (VA). Optum and TriWest are responsible for managing the enrollment and billing for the VA's Community Care Network.

However, when it comes to getting clients and getting referrals, that is still between the agency and their local VA Medical Center or, VA, to send them the clients.

If the referral is approved by the VA, the Veteran may receive home care from a home care agency that is a ‘community provider’ within the CCN.

If the Veteran receives HHA/Homemaker or Respite services at a community provider, Optum or TriWest will be the payer for the services rendered.

How Does The Authorization Process Work?

First, a Veteran needs to be enrolled in the VA healthcare system.

They, or a loved one, can call the Health Eligibility Center number that appears at the bottom of this VA page for more information on their enrollment status or on getting enrolled.

The process of getting a referral through the VA can vary depending on the specific care needs of the Veteran. However, in general, the process of getting a referral typically involves the following steps:

1. Veteran obtains a consult from a VA Primary Care Practitioner (PCP)

Veteran seeks consultation from their PCP within the VA. The PCP evaluates the Veteran's medical needs and determines if additional services, such as home care, are required.

2. Consult is sent to the caseworker

Once the PCP determines the need for home care services, they forward the consult to a designated caseworker within the VA system. The caseworker coordinates and manages the Veteran's care.

3. Caseworker decides the number of hours the Veteran needs

Caseworker reviews the consult and determines the appropriate number of hours of home care services needed. This assessment is based on the Veteran's medical condition, functional limitations, and individual care needs.

4. Caseworker initiates the referral

After determining the required hours, the caseworker initiates the referral process. This involves creating a formal referral or authorization for home care services based on the assessed needs of the Veteran.

5. The referral is sent to you via HSRM, fax, or email

Once the referral is created, they send it to you, the recipient of the referral. The referral can be sent through the Health Share Referral Manager (HSRM) system, fax, or email, depending on the specific communication methods established within the VA system. For navigation ease, here's the HSRM login portal.

6. You accept the Veteran as a client (depending on the VA Medical Center)

Upon receiving the referral, you can review the details of the eligible Veteran's case to determine if you can accept them as a client. The acceptance depends on factors such as the availability of caregivers, the compatibility of your services with the Veteran's needs, and any additional care requirements set forth by the VA Medical Center.

7. You work directly with the Veteran to schedule services

If you accept the Veteran as a client, you establish direct communication with them to coordinate and schedule the care This step involves discussing their preferences, creating a care plan, and ensuring that the necessary arrangements are made to provide the authorized services.

It is important to note that the referral process may vary depending on the specific care needs of the Veteran, as well as the policies and procedures of local VA Medical Centers.

Home care agencies can make this process easier for Veterans by working closely with their local VA Medical Center to understand the referral process and to ensure this process goes as smoothly as possible.

How Many Hours Will The VA Authorize Per Veteran?

The amount of home care hours that the VA authorizes for a Veteran is based on the individual Veteran's needs and can vary widely. Typically, Veterans are assigned between 6 to 16 hours of care per week, but there is no maximum limit.

This means that if a Veteran requires more care, the VA may authorize additional hours to ensure that the Veteran receives the necessary level of care.

It is important to note that the amount of care authorized by the VA may change over time, depending on the Veteran's changing health needs.

Veterans and their families should work closely with their home care agency as well as the VA directly to ensure that the level of care provided meets the Veteran's needs and is authorized by the VA.

How To Bill Optum Or TriWest

A Guide To VA Authorizations, Billing, and Reimbursement (2)

Optum and TriWest typically take under three weeks to pay home care providers if the billing is submitted properly. There are several ways for agencies to submit their billing.

Optum and TriWest both have their own claim submission systems, but they can be slow and may be an additional system to learn for growing agencies.

Home care agencies also have the option to submit their billing through a clearinghouse.

However, it's important to note that a potential issue with this approach is that if an input error is made when adding shift or billing data, the clearinghouse may simply forward these errors to Optum or TriWest, resulting in rejections or short payments.

This may add extra work to agencies as they constantly have to double-check their data before submitting it.

is the only company that has a full spectrum offering from credentialing to billing, education, authorization management, and more with a 99.99% first-pass success rate on all VA billing.

Final Thoughts

This article emphasizes the importance of understanding the VA system, offers step-by-step guidance on authorizations, and also provides billing insights and how Paradigm can simplify the entire process for you.

By utilizing this knowledge, home care agencies can provide essential care for Veterans while ensuring proper reimbursement.

As someone deeply immersed in the intricacies of the VA referral and authorization process, I can confidently guide home care agencies through the complexities of working with Veterans. My expertise extends from the nuanced details of rates and reimbursement to the intricate steps involved in obtaining referrals and authorizations. Allow me to substantiate my credentials by delving into the key concepts outlined in the article.

Rates and Reimbursement: Understanding the financial aspects of providing in-home care to Veterans is crucial. The article rightly points out that the VA offers attractive rates, subject to yearly changes. These rates, dependent on the type of care and geographical location, can be conveniently accessed on the VA's website or through specialized tools. Staying abreast of these changes is essential for accurate billing and financial planning.

Referrals and Authorizations: Navigating the referral and authorization process is pivotal for home care agencies. The article introduces Optum and TriWest as Third-Party Administrators responsible for managing enrollment and billing within the VA's Community Care Network. It emphasizes the need for agencies to establish a connection with their local VA Medical Center to facilitate referrals. The step-by-step breakdown of the authorization process, from consultation to the initiation of referrals, provides a comprehensive understanding of the workflow.

Amount of Authorized Care: A key concern for home care agencies is the amount of care authorized for each Veteran. The article clarifies that the VA determines the hours based on individual needs, typically ranging from 6 to 16 hours per week. Importantly, there is no fixed maximum limit, showcasing the flexibility of the VA system to accommodate evolving health needs. This underscores the necessity for ongoing communication between agencies, Veterans, and the VA to ensure the authorized care aligns with the Veteran's requirements.

Billing with Optum or TriWest: Efficient billing processes are paramount for home care agencies. The article rightly acknowledges the swift payment timelines of Optum and TriWest when billing is submitted accurately. However, it raises valid concerns about potential challenges with their claim submission systems. The recommendation of Paradigm, touted as the only company with a comprehensive offering and a remarkable first-pass success rate, adds a valuable dimension to the discussion, providing a potential solution to streamline billing workflows.

In conclusion, this comprehensive guide not only emphasizes the importance of understanding the VA system but also provides practical insights and solutions. By leveraging this knowledge, home care agencies can navigate the complexities of the VA referral and reimbursement process with confidence, ensuring that essential care for Veterans is provided seamlessly while guaranteeing proper reimbursement.

A Guide To VA Authorizations, Billing, and Reimbursement (2024)
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