Payment to providers under Veterans Choice Program, scheduling of appointments, and accountability of third party administrators under such program

Section 101 of the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146; 38 U.S.C. 1701 note) is amended by adding at the end the following new subsections:

(u)

Prompt payment

(1)

Payment of claims

(A)

In general

Notwithstanding any other provision of this section or any other provision of law, the Secretary shall pay for hospital care or medical services furnished by a health care entity or provider under this section within 45 calendar days upon receipt of a clean paper claim or 30 calendar days upon receipt of a clean electronic claim. (B)

Denial

If a claim is denied, the Secretary shall, within 45 calendar days of denial for a paper claim and 30 calendar days of denial for an electronic claim, notify the health care entity or provider of the reason for denying the claim and what, if any, additional information is required to process the claim. (C)

Additional information

Upon the receipt of additional information described in subparagraph (B) with respect to a denied claim, the Secretary shall ensure that the claim is paid, denied, or otherwise adjudicated within 30 calendar days from the receipt of the requested information. (D)

Invoice basis

This subsection shall only apply to payments made on an invoice basis and shall not apply to capitation or other forms of periodic payment. (2)

Submittal of claims

A health care entity or provider that furnishes hospital care or medical services under this section shall submit to the Secretary a claim for payment for furnishing the hospital care or medical services not later than 180 days after the date on which the health care entity or provider furnished the hospital care or medical services. (3)

Fraudulent claims

(A)

In general

Sections 3729 through 3733 of title 31, United States Code, shall apply to fraudulent claims for payment submitted to the Secretary by a health care entity or provider under this section. (B)

Preclusion of certain providers

Pursuant to regulations prescribed by the Secretary, the Secretary shall bar a health care entity or provider from furnishing hospital care or medical services under this section if the Secretary determines the health care entity or provider has submitted to the Secretary fraudulent health care claims for payment by the Secretary. (4)

Overdue claims

(A)

In general

Any claim that has not been denied with notice, made pending with notice, or paid to a health care entity or provider by the Secretary shall be overdue if the notice or payment is not received by the health care entity or provider within the time periods specified in paragraph (1). (B)

Interest

(i)

In general

If a claim is overdue under this paragraph, the Secretary may, under the requirements established by paragraph (1) and consistent with the provisions of chapter 39 of title 31, United States Code (commonly referred to as the Prompt Payment Act), require that interest be paid on clean claims. (ii)

Computation

Interest paid under clause (i) shall be computed at the rate of interest established by the Secretary of the Treasury under section 3902 of title 31, United States Code, and published in the Federal Register. (C)

Report

Not less frequently than annually, the Secretary shall submit to Congress a report on payment of overdue claims under this paragraph, disaggregated by paper and electronic claims, that includes the following: (i)The amount paid in overdue claims under this paragraph, disaggregated by the amount of the overdue claim and the amount of interest paid on such overdue claim. (ii)The number of such overdue claims and the average number of days late each claim was paid, disaggregated by facility of the Department and Veterans Integrated Service Network region. (5)

Overpayment

(A)

In general

Except as provided in subparagraph (B), the Secretary shall deduct the amount of any overpayment from payments due a health care entity or provider under this section. (B)

Notification of right To dispute

(i)

In general

Deductions may not be made under this paragraph unless the Secretary has made reasonable efforts to notify a health care entity or provider of the right to dispute the existence or amount of such indebtedness and the right to request a compromise of such indebtedness. (ii)

Determination

The Secretary shall make a determination with respect to any dispute or request under clause (i) prior to deducting any overpayment under this paragraph unless the time required to make such a determination before making any deductions would jeopardize the Secretary’s ability to recover the full amount of such indebtedness. (6)

Information and documentation required

(A)

In general

The Secretary shall provide to all health care entities or providers furnishing hospital care or medical services under this section a list of information and documentation that is required to establish a clean claim under this subsection. (B)

Consultation with health care entities

The Secretary shall consult with entities in the health care industry, in the public and private sector, to determine the information and documentation to include in the list under subparagraph (A). (C)

Notification of modifications

If the Secretary modifies the information and documentation included in the list under subparagraph (A), the Secretary shall notify all health care entities or providers described in such subparagraph not later than 30 days before such modifications take effect. (7)

Processing of claims

In processing a claim for compensation for hospital care or medical services furnished by a health care entity or provider under this section, the Secretary shall act through— (A)a non-Department entity that has entered into an agreement with the Secretary under this section; or (B)a non-Department entity that specializes in processing such claims for other Federal agency health care systems. (8)

Treatment of certain outstanding claims

(A)

Report

Not later than 30 days after the date of the enactment of the Veterans Deserve Better Act, the Secretary shall submit to the appropriate committees of Congress a report on the number of claims for payment for hospital care and medical services furnished to eligible veterans under this section that are outstanding as of the date of the submittal of the report. (B)

Outreach to providers

Notwithstanding any other provision of this section, with respect to each health care entity or provider that has an outstanding claim for payment for hospital care and medical services furnished to eligible veterans under this section as of the date of the enactment of the Veterans Deserve Better Act, not later than 45 days after such date of enactment, the Secretary shall either pay the claim, deny the claim, or request additional information regarding the claim. (9)

Definitions

In this subsection: (A)The term appropriate committees of Congress means— (i)the Committee on Veterans’ Affairs and the Committee on Appropriations of the Senate; and (ii)the Committee on Veterans’ Affairs and the Committee on Appropriations of the House of Representatives. (B) The term clean electronic claim means the transmission of data for purposes of payment of covered health care expenses that is submitted to the Secretary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional information from the health care entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services. (C) The term clean paper claim means a paper claim for payment of covered health care expenses that is submitted to the Secretary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional information from the health care entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services. (D) The term fraudulent claims— (i)means the intentional and deliberate misrepresentation of a material fact or facts by a health care entity or provider made to induce the Secretary to pay a claim that was not legally payable to that entity or provider; and (ii)does not include a good faith interpretation by a health care entity or provider of utilization, medical necessity, coding, and billing requirements of the Secretary. (E) The term health care entity or provider means any health care entity or provider that is an entity described in subsection (a)(1)(B), excluding any Federal health care entity or provider. (v)

Information on scheduling appointments

The Secretary shall provide to each eligible veteran who seeks an appointment for care or services under this section the following: (1)Information on the time required for a veteran to make an appointment for such care or services under this section in the region in which the veteran resides. (2)With respect to appointments made through third party administrators— (A)information on what will happen if the third party administrator cannot schedule an appointment for the provision of such care or services; (B)a list of other health care providers in the region in which the veteran resides that are within the network of the third party administrator; and (C)information on how the veteran can file with the Secretary a complaint concerning the handling of an appointment by the third party administrator. (w)

Requirements of third party administrators

(1)

Appointment timing

The Secretary shall ensure that each contract with a third party administrator requires the third party administrator to schedule an appointment for care or services under this section for an eligible veteran not later than five days after the eligible veteran elects to receive such care or services under this section. (2)

Tracking of appointments

The Secretary shall track all appointments for care and services under this section that are scheduled directly through a third party administrator. (3)

Follow-up

The Secretary shall follow up with a third party administrator regarding any appointment for care or services under this section that is pending to be scheduled by the third party administrator for more than 5 days to determine the reason for the delay in scheduling the appointment. (4)

Report on overdue appointments

The Secretary shall require each third party administrator to submit to the Secretary, not later than 30 days after the date of the enactment of the Veterans Deserve Better Act, a list of the appointments that, as of the submittal of the report, have been pending scheduling by the third party administrator for a period of more than 15 days.