VA Authorization Mismatch: What Non-Medicare-Certified Providers Need to Know

Paradigm recently identified a root cause behind recent VA claim denials affecting some home care providers. If you're a non-Medicare-certified agency providing standard home care services to Veterans, this issue may impact you - and there are steps you can take now to resolve it.

Understanding the Issue

VA Medical Centers have been issuing bundled home health authorizations to non-Medicare-certified providers in certain cases. Here's why this creates a problem:

1. Bundled authorizations are designed for Medicare-certified agencies providing post-acute episodic care, akin to Medicare Home Health episodes. Bundled authorizations utilize PDGM methodology, complete with OASIS assessments and HIPPS codes, and require billing on UB-04 forms with HIPPS codes.

2. Non-bundled authorizations are appropriate for non-Medicare-certified agencies providing standard home care services and fee-for-service home health services, which utilize standard HCPCS codes (such as G0151, G0152, G0159, G0299, etc.)

When a non-Medicare-certified provider receives a bundled authorization, they cannot bill correctly under PDGM methodology, resulting in claim denials.

Who Is Affected?

This issue specifically impacts home care and home health providers that meet ALL of the following criteria:

1. You are not Medicare-certified OR are providing non-episodic/standard home care (not skilled home health).

2. You have active authorizations marked as "Skilled Home Health Care Bundled".

Who Is NOT Affected?

If you are a Medicare-certified agency providing episodic care utilizing PDGM methodology and have the capability to complete OASIS assessments, your bundled authorizations are correct, and you should continue billing as usual.

What You Can Do

Paradigm is actively working with TriWest and Optum to facilitate proper authorization assignment protocols. However, the fastest path to resolution requires direct provider action:

1. Verify your Medicare certification status and the type of care you're providing

2. Review your active VA authorizations to identify any marked as "Skilled Home Health Care Bundled"

3. Contact your VAMC to request that bundled authorizations be changed to non-bundled if you are not Medicare-certified or are providing non-episodic care

Paradigm's Commitment

Our team discovered this authorization mismatch through our ongoing claims monitoring and analysis. We're committed to supporting providers through this resolution process and working with payers to ensure proper authorization assignment moving forward.
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If your VAMC has questions about proper authorization assignment or is unable to reissue a non-bundled authorization, please let us know so we can provide additional support through our payer partners.

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