By Dorothy Meindok
The Post Newspaper Veterans Consultant
Who pays who? Don’t be surprised that “ain’t nobody told ya” or that no one has fully explained the rules to outside VA medical doctors, clinics and sometimes even hospitals. It’s confusing and can get complex especially when the rules conflict with individual office policy and procedures in an automated world where employees are continually faced without the empowerment to use logic and reasoning to make simple and obvious decisions based on the operation of law. It isn’t necessarily the Veterans Administration’s job to make sure that third party billers understand the rules, I’ve been told, because it’s published and readily available and while there is a lot of truth in that statement, sometimes the persons at VA haven’t been able to clear the confusions or share where a veteran or their outside physicians can reach out for clear answers, either. What ends up happening is someplace in the mix, the needy veteran is the one that usually suffers the frustrations.
Here’s a live example (shared with permission of a disabled veteran from the Houston/Galveston metroplex): Claudia Duran. She’s a retired nurse, served in the Army overseas, runs a love-filled knitting non-profit that helps keep people warm at night, and was a student who engaged in the historic integration of Hitchcock ISD. She’s a street smart, culturally diverse woman with real life experience who happens to also bear a formal education and she’s been through the ringer in navigating her own health care.
Claudia recently came upon the need for cataract surgery. She’s engaged in and fully compliant in her doctor’s care at VA’s VISN 16, Michael E. DeBakey VA Medical Center as well as her assigned VA community care partner medical providers. Over the past year, she has used community care on numerous occasions for her eye care needs without a hitch. All the eye drops, pre-operative appointments and tests were covered; eventually, she had one of the eye surgeries completed. Then it was time to have her other eye surgery completed, and that’s when things went haywire.
She was scheduled for a mid-January surgery, exactly the same as the one completed on her other eye just two months prior. Her doctor’s office called and stated that they may need to reschedule because the VA had lost her records and they could not find her in the community care system…. Uh, oh. Claudia immediately called to find out what was going on and after hours upon hours of being transferred to and fro, she still did not have an answer, pre-op meds/appointments, or a confirmed surgery date.
She called and asked if I could make some calls with her, and we set about doing that. I am disheartened to say that on one call with community care we were transferred to a live, “triage” nurse for resolution; as one may imagine, a triage nurse is on duty to provide triage not run down billing approvals for community care disconnects. We remained perplexed and at the end of several more hours of reaching out found that although Claudia was still in the system as suspected, the paperwork had been received from her outside eye doctor but that it was not being processed as normal.
One of the issues Claudia faced was that for some reason BOTH entities, the community care representatives and her doctor’s office, failed to engage and simply communicate with one another as medical professionals. Instead, Claudia the patient, was put in the middle of the miscommunications and expected to fill the gaps where it really wasn’t her burden to administer or resolve. It turns out that Claudia’s issue revolved around billing and the laws that govern VA pay versus Medicare. In this instance, it looks like the government budgeteers resolved the issue by sharing the burden of over $40,000 worth of surgery and medical care. Quite honestly, it doesn’t matter to Claudia. She just needs her eye surgery. The good news is the right person was finally reached and her surgery is finally scheduled.
The quickest resolution for Claudia was to bypass the community care system altogether which was an option for her because she is eligible for Medicare. She will have to meet the annual deductible, where with her VA benefits as a 100% service-connected disabled veteran, she would not have one but she decided to absorb the cost rather than fight a system suffering in efforts to overcome growing pains, inexperienced personnel, various occasions of workplace toxicity, acute manpower shortages and oftentimes misplaced, ineffective leadership that fails to lead by example, maybe because they don’t know how or have a blueprint or example to follow above them. Nevertheless, it’s worth the $200 annual deductible for Claudia. But, because not every veteran qualifies for Medicare, we’ll keep praying for VA and working with VA to help meet the mission before us all.
Additionally, there are two veterans’ healthcare bills seeking review and support for veterans to consider: Senate Bill 3603 Veterans Health Care Freedom Act and H.R. 364 Veterans’ True Choice Act of 2021 and since this week, according to the Disabled American Veterans, is Write your Congressman Week, I’d encourage veterans to these options out and write their representatives. You can find out more by visiting Congress.gov.
Here below, I share with you verbatim language from the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services published guide as well as the link to the entire guide which covers veterans billing on page 26. It’s quite informative and covers Medicare billing and priority options outside of VA benefits as well. If you have questions about who pays first, or if your coverage changes, call the Benefits Coordination & Recovery Center toll-free at 1-855-798-2627.TTY users can call 1-855‑797‑2627.
“If you have (or can get) both Medicare and Veterans’ benefits, you can get treatment under either program. However, Medicare is never the secondary payer after the Department of Veterans Affairs (VA). Each time you get health care or see a doctor, you must choose which benefits to use. Medicare can’t pay for the same service that your Veterans’ benefits covered, and your Veterans’ benefits can’t pay for the same service that Medicare covered.
Note: For the VA to pay for services, you must go to a VA facility or have the VA authorize services in a non-VA facility.” (Citing – U.S. Dept. of Health & Human Services, CMS Product No.02179, Revised September 2021.”)
Like in Claudia’s matter above, the reason she must pay her Medicare deductible is because she opted to use Medicare as primary payor over waiting for VA to find her in the system & approve the second surgery. Because she opted for Medicare to pay first, federal rules and regulations essentially prevent VA from paying for the same surgery or any financial deficiencies resulting from the choice, such as her annual deductible.
“Are there any situations when both Medicare and the VA may pay?
Yes. If the VA authorizes services in a non-VA hospital but didn’t authorize all of the services you get during your hospital stay, then Medicare may pay for the Medicare-covered services the VA didn’t authorize.” Id.
Knowing that this rare and blended pay structure is not normally pre-determined and is usually a construct of medical necessity, I would advise against assuming that one or the other will automatically offset the other and the bill will get paid. Oftentimes, not making sure that billing is secure and transparent leaves unknowing veterans facing bill collectors for debts they have no idea how to deal with.
“If the doctor accepts you as a patient and bills the VA for VA-authorized services, the doctor must accept the VA’s payment as payment in full. The doctor can’t bill you or Medicare for these services.
If your doctor doesn’t accept the fee-basis ID card, you’ll need to file a claim with the VA yourself. The VA will pay the approved amount either to you or to your doctor.” Id.
If a veteran finds themselves in this position, they can call the VA Adverse Credit Helpline at 877-881-7618 to help resolve adverse credit reporting and debt collection issues as a result of using community care.
Here’s the link to this valuable guide: https://www.medicare.gov/sites/default/files/2021-10/02179-Medicare-and-other-health-benefits-your-guide-to-who-pays-first.pdf
See you next week! DDM
Dorothy Meindok is The Post Newspaper’s Veterans Consultant. Ms. Meindok served her nation in the United States Navy and is currently a practicing lawyer advocating for our nation’s veterans. Her column appears on Sundays.
