Managing Veterans Affairs (VA) billing and claims requires a proactive approach to prevent rejections and denials. With over 9.1 million veterans enrolled in the VA healthcare system as of 2024—marking a historic 30% increase in enrollment from the previous year—providers face complex challenges around eligibility, authorization, timely filing, and payer coordination. This surge in enrollment, driven by the bipartisan PACT Act and occurring across all 50 states, has created an unprecedented need for efficient revenue cycle management. The 401,006 new veterans enrolled in the past year represent the highest annual enrollment in at least five years, nearly 50% above pandemic-era numbers. To help healthcare providers navigate this expanding system and streamline their VA billing processes while improving financial performance, here are five essential best practices.
- Patient Eligibility Verification and Pre-Authorization Checks
Effective VA claims management starts with accurately verifying patient eligibility and pre-authorization status. Each patient’s VA eligibility status should be assessed for both service-connected and non-service-connected conditions. Having an accurate record of whether care is authorized or unauthorized is critical, as each category has unique filing requirements.
Eligibility Verification: Check eligibility using the VA’s 10-digit member ID on their card; however, do not use this number for billing, as it’s not a valid billing ID. Verification tools such as VACCM portals (Optum and TriWest) can expedite eligibility checks and claim status inquiries.
Pre-Authorization Requirements: Obtain pre-authorization for non-emergency services to avoid claim denials. For service-connected treatments, confirm that necessary authorizations align with treatment plans and valid dates.
- Efficient Coordination of Benefits and Notifications
Coordination of benefits (COB) ensures that claims are filed correctly when the VA is the payer of last resort. Unauthorized care, such as emergency room visits, requires additional COB considerations, as the VA pays secondary to commercial insurers and Medicare in these cases. Unauthorized ER claims need to include timely notifications within a 72-hour window to ensure potential VA payment.
Emergency Notifications: For emergent care, submit notifications promptly, ideally on the same day. Working within a strict 72-hour window is essential to avoid rejections, and it’s helpful to note that TriWest and Optum vary in their flexibility regarding backdated urgent care referrals.
Service-Connected vs. Unauthorized Care: Confirm whether services are related to military service; this status impacts VA payment obligation. For urgent and unauthorized care, prompt notification can improve the likelihood of reimbursement, even if there are delays in reaching the patient or payer.
- Optimize Claims Management and Billing Processes
A successful VA billing process is proactive. Consistent claims management reduces errors and rejections, but it requires attention to detail and understanding the VA’s specific claim requirements. Missing authorizations, late notifications, or incomplete details can lead to payment delays or denials.
Data Accuracy: Ensure registration details (e.g., patient name, spelling, and ID format) are correct to avoid rejections. Claims denials often stem from simple errors, like incorrect spelling or mismatched authorization numbers.
Timely Filing Compliance: Each payer has its own timely filing guidelines. Unauthorized claims have shorter filing windows, making it essential to file promptly, especially for rejected claims, as VA front-end 277 rejections don’t prove submission timeliness.
- Utilize VA Tools and Portals for Real-Time Claim Tracking
Accessing VA and third-party administrator tools is vital for claims tracking and status updates. The VA, Optum, and TriWest offer user-friendly portals and direct phone support for claims inquiries, eligibility checks, and authorization verification. For additional support, Aspirion’s RPA automation can further streamline claims status checks.
Available Resources: The VA provides the Customer Engagement Portal (CEP) for claims status on directly submitted claims. Optum and TriWest’s portals are helpful for eligibility, authorization, and claims updates. Using Availity’s payer space for TriWest and dedicated portals for Optum can also speed up authorization and claims resolution.
Proactive Follow-Up: Take advantage of chat functions on TPA portals to reach live representatives quickly and follow up on claims directly through these tools to reduce delays.
- Track Metrics and Policy Changes to Enhance Revenue Cycle
Tracking claim-performance metrics enables healthcare providers to pinpoint inefficiencies and adjust their processes accordingly. Monitoring policy changes is equally important, as VA billing policies frequently evolve. Staying informed about updated filing deadlines, policy requirements, and eligibility changes is critical for success in this field.
Monitor Resubmission and Reconsideration Rates: Resubmissions due to registration errors, authorization mismatches, and coding issues highlight areas for potential workflow improvements. Examining why claims require reconsideration can reveal payer-specific trends or internal-process gaps that need to be addressed.
Stay Updated on VA Policy Changes: Policy changes—like CHAMPVA’s recent timely filing adjustments and the upcoming transition from social security numbers to Medicare Beneficiary Identifiers (MBI)—impact claims processing. Keep up with the VA’s provider advisories to stay informed and respond effectively to these changes.
Conclusion
Implementing these best practices can improve the accuracy and efficiency of VA claims processing. From verifying patient eligibility to maintaining compliance with timely filing rules and staying current on policy updates, these steps will support a smoother billing cycle and more predictable revenue. For healthcare providers, following these best practices not only reduces claims rejections and denials but also fosters a streamlined, proactive approach to managing VA claims. To learn more, watch our on-demand VA webinar here.
Ready to streamline your VA claims process? Partner with Aspirion to protect your financial health and boost your ability to serve veterans with excellence and compassion. Our expertise ensures you can focus on delivering top-quality care to those who have served our nation. Connect with us today to learn more!
