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Old 6 August 2019, 19:28
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wildman43 wildman43 is offline
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Non-VA Emergency Care Claims Inappropriately Denied and Rejected

I did a copy an paste on this article web link was not working correct

Non-VA Emergency Care Claims Inappropriately Denied and Rejected

Veterans Affairs Office of Inspector General (OIG) sent this bulletin at 08/06/2019 04:25 PM EDT

In response to a congressional request, the VA Office of Inspector General (OIG) conducted this audit to determine whether processors of non-VA emergency care claim inappropriately denied or rejected the claims, and, if so, whether the cause was pressure to meet production standards.

The OIG conducted an accuracy review of claims for emergency medical care obtained outside VA and found that 31 percent of denied or rejected non-VA emergency care claimsówith an estimated billed amount of $716 millionówere inappropriately processed from April 1 through September 30, 2017, creating the risk of undue financial burden to an estimated 60,800 veterans. The review revealed that some of those denied and rejected claims should have been approved.

The OIG estimated from its sample that about 17,400 veteransówith related bills totaling approximately $53.3 millionówere negatively affected.

The remaining processing errors still created a risk that the claimants did not receive complete and accurate information regarding why their claim was not approved, and therefore could not effectively respond with necessary information to obtain claim approval and payment. The OIG concluded there was a significant risk that some of the errors identified in this audit resulted from pressure to meet production targets, insufficient quality assurance of claims processing accuracy, and incentives associated with meeting production targets.

The OIG made 11 recommendations to improve the accuracy of non-VA emergency claims processing that included addressing the culture of prioritizing claims productivity over accuracy, improving performance evaluation standards and review processes, tying incentives to all performance standards rather than just production quantity, reevaluating inappropriately processed claims, and improving internal and external communication about claim status.
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Old 6 August 2019, 20:10
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Ole crusty bastard Ole crusty bastard is offline
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Location: Port Charlotte FL
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I went through this crap a few months ago. I ended up having to drive 80 miles to the VA Administrative Office (at Pay Pines VA). I had a DAV rep guide me through the proper answers. The interview was by way of video with a lady in D.C.. Results were; as I did notify VA before going to Emergency Room and they OK'ed going, no money out of my pocket. Decision came about 90 days after interview.

I think the key is to be the squeaky wheel when you think you are getting screwed.
...when in doubt...over prime.
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Old 6 August 2019, 20:39
Gsniper Gsniper is online now
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The VA fucked something up? No way.
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Old 10 September 2019, 09:30
Semp Semp is offline
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Congress should be put in the VA system. I think things would improve quickly.
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Old 10 September 2019, 13:02
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wildman43 wildman43 is offline
Never to old to learn
Join Date: May 2012
Location: California
Posts: 3,469
You got good doctors & somewhat Doctors at the V.A. Then you have the admin individuals that are GS 4 or 5 level an a supervisor that might be a GS 6, they have a quota to fill, my wording 98.9% of the time they have not been trained or take the time to learn what the regulations state or mean.

This last year I have not been working at the V.A. due to my wife health & mine. I started back yesterday an I know I have a lot of updates etc. to catch up on!.

The rate of change over for the clerks, is unbelievable. As soon as they are pass their probation time they are looking for a new area to work in. (At a higher pay GS-4 to a GS-5) sometimes.

Last edited by wildman43; 10 September 2019 at 13:05. Reason: wording
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