Phil Roe

Submission for the Record- Rep. Phil Roe                                 HVAC FC Hearing 10/7/2015

I have been trying put together a summary of my experience with the Veterans Choice Program (VCP) and to get the perspective of both the VA and TriWest employees since they each blame each other.  I am hoping somewhere in the middle lies the answer as to where the problems are occurring.  Because I have been given so many different answers on how this step by step process works, I called the Non VA Care office at our VA Medical Center to talk to the people actually doing the work.  One of the staff members, who was very receptive over the phone and had many examples to share, had planned to give me an outline of the process along with some of the problems they experience, but instead was told to refer me to Public Affairs, who cannot give the answers we need to solve problems. 

There are two ways that a Veteran can become eligible for care under VCP provisions:  1)  30-day wait list and 2) Resides 40-miles or more from nearest VA medical facility.  Most of the problems I see involve the 30-day wait list. 

Below is information which has been given to me since the rollout of this program.  In my experience, there appears to be a breakdown somewhere in this process but have been unable to get any clear answers on how to fix it.  VAMC blames TriWest and TriWest blames VAMC.

• Eligibility is determined by VAMC/primary care doctor (if appointment is 30 days past the clinically indicated date)
• Non VA Care staff then uploads list of eligible veterans to VA’s Central Office nightly & the veteran is told to wait 5-7 days and then call TriWest
• Central Office then sends the information to TriWest, which can take 3-7 days.  
• Consults do not get submitted, medical documentation doesn’t get uploaded, and authorizations get canceled leaving the veteran on a merry-go-round with VAMC & TriWest.

TriWest perspective

The Veteran’s servicing VAMC sends a notification to TriWest indicating that the Veteran has waited 30 days or is expected to wait 30 days or more for a specific type of care (podiatry, cardiology, neurology, orthopedics, dermatology, etc.). At the same time the notification is sent or soon after, the servicing VAMC sends a consultation to TriWest indicating what type of care the Veteran needs in the previously indicated specialty. Once these two criteria have been met, a TriWest patient services representative (PSR) contacts the Veteran to inquire about his or her appointment preferences and then searches for a provider that can meet the Veteran’s needs in terms of appointment timeliness and a travel distance that falls within the VA’s access to care standards. Once the appointment is made, the Veteran is notified and TriWest arranges for the provider to receive from the Veteran’s servicing VAMC the appropriate medical records pertaining to the care being sought. An important thing to note regarding 30-day wait list notifications is that under this provision, the Veteran is only permitted to be appointed in the specialty for which he or she has been waiting 30-days or more for an appointment. If the provider the Veteran was appointed to see feels that additional care is needed, that provider must submit to TriWest a secondary authorization request (SAR) that TriWest would then forward to the Veteran’s servicing VAMC for consideration. Any additional appointing depends on the VAMC response.

Network of physicians is a problem.

Need more staff.

VAMC perspective:

Non VA Care staff were given no training or SOP on this program and they are basically “winging it”. 

Our local Non VA Care staff was 5 – increased to 15 and still struggling to meet demands of thousands of appointments through the Choice Program.  (There is talk of calling each patient for every appointment to make sure they want to keep it.  If patient indicates they do NOT want to keep, VA staff will still be required to call them 2 times/mth until the appt. date has passed to make sure they haven’t changed their mind.  This will be a waste of resources they do not currently have.)

Outpatient clinics should be required to add patients to the electronic wait list rather than sending over to Non VA Care staff  - this causes delays for the veteran

TriWest portal needs to be more user friendly for vendors; Secondary authorizations are a disaster.

Private doctors do not like jumping through all the hoops of the Choice Program & are saying they must give up a % of their fee to TriWest in order for TriWest to file their claim with VA. 

Clinics (i.e. pulmonary, chiropractic) are closing at our VAMC because the doctors are fed up with everything going on.

Non VA Care staff believes putting the funding back into Non VA Care and out of the hands of TriWest will alleviate these problems.