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Lindsey Davis Stover, a partner in Edwards, Davis Stover & Associates, LLC, former Congressman Chet Edwards, an adviser to TriWest Healthcare Alliance, and Joseph Enderle, director of purchased care operations for the U.S. Department of Veterans Affairs.

HARLINGEN, RGV – When the VA does not pay healthcare providers that look after veterans in a timely manner they tend to leave the network, thus reducing access to care.

That has been happening in the Rio Grande Valley, just as it has in other parts of the country.

However, a concerted effort to improve the VA Community Care (VACC) program in Deep South Texas spearheaded by U.S. Rep. Rubén Hinojosa in conjunction with Valley Baptist Health System, Doctors Hospital at Renaissance, the Veterans Health Administration, and TriWest Healthcare Alliance seems to be paying dividends.

A few months back the percentage of payment claims the VA was denying from Valley Baptist was in the high 50s. Now, it is down to about 11 percent, said Art Rangel, Jr., system vice president for administration at Valley Baptist Health System.

“We have been meeting for the last three or four months and reviewing processes, specific claims and trying to better understand where the defects were originating from. We have found opportunity at our end and the VA end and so bringing two heads together we have provided a more efficient process,” Rangel said.

“For four or five months we have been working with Tri-West. We have had team meetings once a week, just looking at denials. Slowly but surely we have been making in-roads. You start to see the efficiencies come into place. They are not immediate, not for the amount of claims we deal with, but we have seen big improvements recently.”

Why veterans were angry

Hinojosa said it was “imperative” that the VACC program in Deep South Texas be vastly improved. VACC purchases health care for eligible veterans when a VA Medical Center, clinic, or other federal facility is not available to furnish that care. TriWest administers two VACC programs – Patient-Centered Community Care (PC3) and Veterans Choice Program (VCP) – on behalf of the VA in 28 states including Texas.

“I have been working diligently in partnership with the Department of Veterans Affairs, TriWest, and the excellent health care providers of Deep South Texas towards our common goal of community care coordination,” Hinojosa said. “I was pleased to come together this week to review the strides we have made at the midpoint of a 90-day effort. As a result of our combined efforts and continuous communication, we have identified many root causes of delayed or denied claim payments.”

The community care project for South Texas veterans began in May 2016 when Hinojosa hosted a Veterans Community Care Roundtable with VA, TriWest, and several Veteran Service Organization Post Commanders. At this roundtable, Hinojosa said, veterans expressed confusion and difficulties utilizing VACC.

“We found this out by going to places like the VFW there in McAllen and actually talking to the veterans. We wanted to find out why were they so angry. Well, they were angry because they were unable to get an appointment and sometimes the appointment was 30, 45 days away. The veterans told us that there are these doctors that would not even see them. They said the doctors told them they had not been paid,” Hinojosa said.

“We looked into it and sure enough I met with a group of doctors and they told us that there were accounts receivables that were six months, sometimes up to a year old, that had not been paid. Then I talked to the hospital administrators and they were in the same shape. I realized it was a huge problem.”

Hinojosa followed up in June 2016 with an additional roundtable designed to improve communication between the VA, TriWest, and community providers. Hinojosa said that during this event, many providers voiced their frustrations and challenges in response to an inordinately high amount of accounts receivable. As a result, Hinojosa said, TriWest committed to resolve outstanding claims in the Deep South Texas region within 90 days, and include a midpoint progress report for accountability.

Midpoint progress report

The midpoint progress report occurred last week. For two days, Hinojosa, Valley Baptist, the VA and TriWest met. On the first day, TriWest and the VA offered educational information to local medical providers, with each provider having the opportunity to meet one-on-one with TriWest and VA representatives to address their questions regarding VACC programs, authorization, and billing.

On the second day, many of the same individuals reunited at Valley Baptist Health System. Hinojosa said the meeting, which the Rio Grande Guardian attended, served as a midpoint progress report for the 90-day effort. Among the advances reported was a 20 percent increase in claims paid within 30 days since the initiation of the partnership.

Those in attendance reviewed key aspects of care coordination including authorization timelines, methods to submit claims and medical documentation, and communication of claim denials. Those present said further opportunities for improvement were identified.

Interviewed by the Rio Grande Guardian, Joe Enderle, director of claims, adjudication and reimbursement for the Veterans Health Administration, acknowledged there have been problems with VACC in the Valley.

“We recognize that the claims processing has some issues and some problems but ultimately the goal is helping veterans, making sure that they receive the care they need, when they need it, at the right place, at the right time,” Enderle said. “Our responsibility is to facilitate that. That is our mission. As long as we can provide that care for our veterans and also take care of the providers we are partnered with, making sure they are paid timely, so that care is not interrupted, we will be doing our job.”

Dr. Frank ‘Mac’ Maguire, chief medical officer for TriWest, said his organization has about 22,000 health care provider partners in Texas taking care of 137,00 veterans.

“The entire foundation of the Veterans Choice Program is built on the providers. If you do not have the providers, you cannot provide the services that the veterans deserve. These services need to be very convenient. They need to be of high quality and they need to meet the veterans needs in a very timely way,” Maguire told the Rio Grande Guardian.

“It is all about having good partners. As you saw in the meeting today, Valley Baptist is a perfect example of that. They have invested their senior leadership’s time and energy in trying to make this process work better. I can only say we are equally committed to doing so. If we can’t address all these issues the Congressman has brought up, regarding getting the claims paid, then obviously it erodes the faith of the providers in the community. As the Congressman said, our providers want to take care of the veterans. They truly want to. We just need to make it easier for them to do so.”

Falling out of the network

Manny Vela, CEO of Valley Baptist, said he and his executive team have a saying: Every day is Veterans Day at Valley Baptist. “We take that to heart and we mean it as sincerely as we can because it is our opportunity to give back to the heroes in our society. Those who have sacrificed on behalf of our country,” Vela said.

“Unfortunately, what was happening is there were doctors in hospitals falling out of network primarily because of the issues in regards to payment, etc. We’ve seen an incredible willingness from TriWest and the VA to sit down and try to resolve some of the issues that we’ve all faced as providers. And, at the end of the day, the result would simply be doctors and hospitals wanting to come back into network and continue to serve our veterans which is exactly where it should be. And I believe we’re all aligned in regards to that stated goal.”

Vela said Valley Baptist “couldn’t be more proud” than to have a seat at the table trying to find a resolution to these issues.

“I think if you’re objective about these things and introspective as we all have been in this process you recognize in fact that there is room for improvements on multiple fronts. I think every party at the table today has recognized that including Valley Baptist, TriWest and the VA and the result will be a much more refined model that will better serve our veterans.”

Rangel, system vice president for administration at Valley Baptist, echoed Vela in saying Valley Baptist is proud to serve South Texas veterans.

“Like any other business, the expectation is a payment for service rendered within a certain time frame. The challenge is then to connect the dots with how the VA works, how TriWest works, how Valley Baptist works, to better streamline the processes,” Rangel said.  “Today, we are two steps closer. I believe that as we continue to get together to resolve these issues, you are going to have a better process that can stand up in the business world. In the business world, if you are not performing at a certain level you are out. Somebody is going to replace you. We need to strive to get to that type of level in healthcare and I think we have taken the initial steps.”

Asked what improvements veterans will notice as this community care project takes off, Congressman Hinojosa said:

“They will see an increase the number of doctors and the number of medical facilities. That, automatically, will expedite giving appointments to veterans, men or women, who need medical services. It will be a win-win situation because if we have a healthy population, many more veterans will be able to work and contribute to the economic successes of South Texas, from San Antonio to Brownsville, Harlingen, McAllen, Edinburg and Laredo.”

Investing in employees

Hinojosa added: “It was amazing to me how willing both Valley Baptist and Doctors Hospital at Renaissance are in investing in training employees that work in the office for the billing. Investing in their employees training, we will improve the accounts receivables, the collections, and once the money is flowing into the doctors, the hospitals and the providers, they will be much more willing to take new patients.”

Doctors Hospital at Renaissance was not represented at the meeting at Valley Baptist. However, its interim CEO, Dr. Carlos Cardenas, told the Rio Grande Guardian that his health system will play a “key role” in the community care project.

“We have had meetings with Tri-West to try to improve turnaround time on reimbursements, which are obviously important for folks in the revenue cycle. This is very important in order to maintain the economic stability of any organization in healthcare that works for veterans. We want to do whatever we can to remove impediments and make it as streamlined as possible,” Cardenas said.

“If we can get all the stakeholders to the table to commit to making changes and share thoughts on how we can improve the system, then a lot of great things can happen. Certainly, there has been a willingness on the part of the Congressman and others, including Tri-West and others to see what we can do to improve the process.”

Editor’s Note: Reporter Ena Capucion contributed to this story from Edinburg, Texas. This is the first in a two-part series on the VA Community Care program in Deep South Texas. Part Two will be published on Friday, September, 9, 2016.