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VA Healthcare Purchased from the Community. Purchased Care Program Integrity Tools. Department of Program Integrity Denver, Colorado May 2013. Topics. Introduction and Overview of the Program Integrity Tools Frequently Asked Questions and rejection Reasons

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Va healthcare purchased from the community

VA HealthcarePurchased from the Community

Purchased Care

Program Integrity Tools

Department of Program Integrity

Denver, Colorado

May 2013


Topics

Topics

  • Introduction and Overview of the Program Integrity Tools

  • Frequently Asked Questions and rejection Reasons

  • Benefits of the Program Integrity Tools


Program integrity tools pit

VA &

Source

Systems

Program Integrity Tools (PIT)

Patient

Payment

Medical

Provider

Clearinghouse

electronic

paper

PIT

High level overview of the flow of claims for the PIT


Claims scoring tool

Claims Scoring Tool

Hard Rules

SCORING

Statistical

  • Hard Rules

    • Predefined FWA logical rules

    • Examples:

      • LEIE

      • Duplicate claims

        Statistical

  • Fraud Abuse Management System

    (FAMS) identifies healthcare providers exhibiting suspicious billing patterns

  • FAMS contains integrated data mining, business logic, and reporting


Faq providers

FAQ - Providers

  • Frequently Asked Questions by Providers

  • Will address providers concerns regarding:

    • Delay in payment

    • How to bill appropriately

    • What will be displayed on their PFAR

    • What to do if a claim is rejected by the PIT

    • Informational resources available to them regarding the PIT


Rejection reasons

Rejection Reasons

  • Match the rejection reason on the VA EOB to the chart on the website.


Benefits of the program integrity tools

Benefits of the Program Integrity Tools

  • Benefits

    • Safeguards the taxpayer’s investment

    • Prevents improper or fraudulent payments before they are made

    • Providers receive education on billing rules

    • Providers will receive educational letters

    • Affirms Veterans Affairs’ commitment to excellence to our nation’s Veterans and Beneficiaries, and stakeholders


Program integrity website

Program Integrity Website

The Department of Program Integrity website will be available Summer 2013.

The website will provide information on fraud news, helpful training and development, valuable resources and other necessary tools to help fight against Fraud, Waste and Abuse.

Look for additional news and updates advertised on the National Non-VA Care Program Office website under Providers.


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