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Chapter 4

Compliance

Last updated
Reading time
12 min
Sections
6
On this page (6)
  1. Holiday Rates, Mileage and Overtime
  2. Registered Nurse (RN) Services
  3. Authorizations and Consult
  4. Shifts, Billing, and Coding
  5. Re-credentialing
  6. Staying On Top of Alerts and Advisories

This section is non-exhaustive and covers the most common scenarios gathered from our experience serving over 2000 VACCN providers, communications received directly from the VA, Optum and TriWest documentation, various provider experiences, and direct contact from VAMCs nationwide.

It is vital for all providers to follow these guidelines. It is also important to note that these rules are ever-changing, and might differ in the future, or might be different at your local VAMC. If you have any questions or uncertainties, please consult with your VA Social Worker, case manager, Optum, TriWest, or Paradigm for guidance.

While we aim to provide accurate and up-to-date information in this guide, no guarantees are made to the completeness, relevance, or accuracy of the contents. It is designed for educational purposes only and should not be considered professional advice.

4.1Holiday Rates, Mileage and Overtime

Under no circumstances will the VA cover mileage, overtime, or holiday rates.

  • Mileage: You cannot bill mileage to the VA, Optum, or TriWest.
  • Transportation: You cannot bill for transporting a VA client. Moreover, a caregiver should only transport a Veteran client if it is explicitly allowed in the consult or with written permission from the VA.
  • Holiday Rates: The VA does not pay 1.5X the hourly rate for holidays, even if the provider is obligated to pay this to the caregiver under state or federal regulations. Providers are not permitted to add extra billing units to invoices in an attempt to compensate for, or represent, the increased holiday rate.
  • Overtime Rates: The VA does not pay 1.5X the hourly rate for overtime, even if the provider is obligated to pay this to the caregiver under state or federal regulations. Providers are not permitted to add extra billing units to invoices in an attempt to compensate for, or represent, the increased overtime rate.
  • Balance Billing: Charging the client the balance to cover your costs for overtime, holiday pay, and/or rate differences is never allowed.

4.2Registered Nurse (RN) Services

In certain situations, the VA permits agencies to dispatch RNs for supervisory visits (procedure code G0162), but strict guidelines must be followed.

  • State Mandated: RNs are permitted to conduct initial assessments and periodic supervisory visits only if it is mandated by the state, and only up to the limit specified in the state mandate. These visits cannot be conducted by an office supervisor or anyone who is not a Registered Nurse (RN).
  • No State Mandate: If your agency operates in a state without an RN supervisory visit mandate, you may be able to bill for supervisory visits or an initial assessment conducted by a Registered Nurse. Consult the SEOC section for more information. For more clarity, please reach out to the caseworker for further instruction.
  • Written Authorization: If your local Veterans Affairs Medical Center (VAMC) requires you to conduct an initial RN assessment or a supervisory visit by an RN, ensure you have this directive in writing. You can never bill for an assessment or supervisory visit, if not done by an RN. If authorized, LPN assessments or office assessments can be done, but should never bill using the G0162 code.
  • Billing Unit: RN Supervisory visits must be billed in 15-minute units only. Charging for a full 1-hour visit is not allowed under any circumstances. An hour-long visit must be billed as four separate 15-minute units. According to CMS Guidelines, rounding to the nearest 15 minutes, either up or down, may be permissible.
  • Two Hour Limit: An initial RN assessment or RN supervisory visit cannot exceed 2 hours. Your local VAMC may further restrict this to a shorter period.
  • Visit Frequency: VAMCs may have distinct guidelines on RN supervisory visit frequency. For example, one might authorize visits every 60 days and another every 45 days. Ensure you follow these guidelines precisely.

Unit Number of Minutes:

  • 1 unit ≥ 8 minutes - 22 minutes
  • 2 units ≥ 23 minutes - 37 minutes
  • 3 units ≥ 38 minutes - 52 minutes
  • 4 units ≥ 53 minutes - 67 minutes
  • 5 units ≥ 68 minutes - 82 minutes
  • 6 units ≥ 83 minutes - 97 minutes
  • 7 units ≥ 98 minutes - 112 minutes
  • 8 units ≥ 113 minutes - 127 minutes

4.3Authorizations and Consult

Authorizations and consults should be thoroughly reviewed prior to starting care. Most of the time, a "consult" is sent along with the referral which includes important instructions or directives.

  • SEOC (Standardized Episode of Care): This term refers to a specific section in all referrals. The SEOC outlines the services authorized by the VA for the client.
  • Consult: This is usually part of the referral document but may be sent separately or can be found in HSRM. The 'Consult' section contains specific instructions and details regarding the services to be provided. The directives found in this section should be given priority over other instructions.
  • Authorization: In our documentation and communications, the terms 'authorization' and 'referral' are used interchangeably. These terms refer to VA Form 10-7080, which is sent to you by the VA to officially authorize the types of care and services your agency will provide to a Veteran client.
  • Consult Adherence: Always follow what is instructed in the 'consult' even if it differs from what is written in the SEOC section of the referral. If the SEOC allows for 20 hours of care a week but the consult states that you should only provide 10 hours, the consult takes precedence.
  • Additional Hours Within SEOC Limits: If a client requires additional hours beyond what's outlined in the consult but remains within the SEOC limits, you must contact the social worker to secure approval for the extra hours and to have the consult updated. You can also advise the client or their family to request more hours for ADL needs. It's recommended to have documentation to prove the need for these extra hours.
  • Additional Hours Outside of SEOC Limits: If the client needs more hours than is authorized by the SEOC, you must ask the social worker for permission. If the hours are granted, the social worker will have to create a new referral, SEOC, and consult before you provide the additional care.
  • Authorization and Renewals: Be attentive to the duration of service authorizations, as this can vary among VAMCs. Make note of the coverage dates and prioritize timely renewals, which may include submitting RFS forms or other required documentation. It's crucial to adhere to each VAMC's unique guidelines and deadlines, as some may have specific processes they prefer providers to follow. Ensure you communicate with the social worker or case manager to ensure there are no lapses in coverage. Never render care without a valid authorization on file.
  • Benefit Hours: VA benefit hours are always Sunday through Saturday. They are never Monday through Sunday, nor based on your payroll week, irrespective of what a VA Social Worker may have told you.
  • Unused Hour Policy: Authorized hours NEVER roll over from week to week.
  • Additional Caregivers: If the VA Social Worker gives written approval in the consult for two caregivers to attend to a client due to a severe condition, you may bill for both caregivers. However, the combined total of billed hours must not exceed the number of hours approved in the consult.
  • Missing Consult Documentation: If the VA did not share a consult with you, ask them for it or check HSRM (HealthShare Referral Manager) for it. You want to make sure that you are armed with the full scope of knowledge of the client's condition and the care that should be provided. Not knowing or saying you did not receive the consult is not a valid excuse.
  • Hours Not Stipulated: If the consultation does not specify the number of care hours for the client, it is up to the provider to discuss and agree upon the number of hours with the client or their family. However, the agreed-upon hours must fall within the limits set by the referral's SEOC.
  • Specific Days Outlined: If the consultation outlines specific days for the care shifts, the provider should adhere to that schedule. If the client's needs do not align with the specified schedule, contact the VA Social Worker to request permission for schedule adjustments.
  • Specified Care: If the consultation specifies the type of care required - such as 1 hour of bathing and 2 hours of Homemaker services - you should strictly adhere to these guidelines and provide only the specified care.
  • Additional Assistance: If the client clearly requires additional help with their Activities of Daily Living (ADLs), consult the VA Social Worker to confirm whether you can offer more ADL assistance during the shift. Make sure to obtain written confirmation for any adjustments to the care plan. You can also advise the client or their family to request more hours for ADL needs. It's recommended to have documentation to prove the need for these extra hours.
  • Consult Limitations: Social workers and care coordinators within VA Medical Centers are sometimes limited in what they put in the consult and may order less care than what is needed. If this is the case, providers should carefully document the client's condition and their Activities of Daily Living (ADLs) needs. This information, along with any relevant supporting documents, should be communicated to the VA Social Worker.

4.4Shifts, Billing, and Coding

It's crucial for providers, scheduling coordinators, and billing staff to fully comprehend these guidelines to ensure compliance.

  • Rounding Units: According to CMS Guidelines, rounding to the nearest 15 minutes, either up or down, may be permissible. This is not to be done by guesswork. See chart on page 2.
  • Cancelled Shifts: If a client or caregiver cancels a shift, irrespective of what the agency policy is for canceled shifts, they cannot be billed to the VA.
  • Incomplete Shifts: You cannot bill the VA, Optum, or TriWest for uncompleted portions of shifts that were cut short. For instance, if a caregiver was scheduled for a 1-hour shift but was dismissed early by the client, having provided only 45 minutes of care, you are only permitted to bill for those 45 minutes. This is irrespective of what the agency policy states regarding the matter.
  • Balance Billing: Under no circumstances can you balance bill the client for services authorized by the VA, TriWest, or Optum. As stated in the TriWest handbook, "Payments made by TriWest or VA shall be considered payment in full under CCN. Providers may not impose additional charges... the Veteran for covered services."
  • Additional Private Hours: Veteran clients are allowed to privately pay for hours above what is authorized by the VA. This is not considered balance billing, provided you have an agreement with your client for private hours.
  • Billing Limit: Billing for more than 24 hours in a single day is not permitted. For instance, if a provider is authorized for two caregivers and sends each for 15 hours to a client, billing the VA for 30 hours is not allowed, even if this is within the authorized weekly hours. The maximum billable time for one Date of Service (DOS) is 24 hours. Shifting dates on your billing to fit within these constraints and evade overages is strictly prohibited.
  • Client Specificity: Providers should only provide care and bill for the client specifically named in the referral or consult.
  • Billing Accuracy: If Electronic Visit Verification (EVV) is available, you must bill based on the caregiver's actual clock-in and clock-out times. When EVV is not available, timesheets must be signed by the caregiver and, preferably, the client to verify the time care was rendered. In all cases, only bill for the care actually provided.
  • VAMC Instructions: Different VAMCs may have unique guidelines. Some explicitly instruct agencies to focus on Activities of Daily Living (ADLs) and allocate time for Homemaker tasks only if time allows for it. Others specify which billing codes to use for different types of care during a single shift. Given these varying and ever-changing consults, it's essential to fully understand each VAMC's specific expectations before starting the care and processing billing.
  • Agency Management Software Settings: For VA clients, it may become necessary to override default shift minimums or adjust other AMS settings to meet their specific care needs and to align with VA regulations.
  • Care Notes and Billing: It's crucial that your care notes accurately reflect the services provided, regardless of the type of care. Any discrepancies between your care notes and what is billed could lead to billing or compliance issues. For example, if ADL care was provided, this must be clearly indicated in your care notes.
  • Billing Limitations: Under no circumstances should your billing exceed the parameters set forth in the consult.
  • Fraudulent Billing: Creating false shifts to collect additional funds for services that were not actually provided is fraudulent and strictly prohibited.
  • Service and Date Integrity: Manipulating services or altering the dates that care was provided in order to fit within the authorization or to evade overages is strictly prohibited.
  • Overnight Shifts: For shifts that span from one day into the next, billing must be divided to allocate hours for each respective day. For example, an 8-hour shift running from 10 PM to 6 AM would be billed as 2 hours for the first day and 6 hours for the following day. Be aware that Saturday/Sunday overnight shifts will impact the benefit hours available for the coming week.
  • Family Caregivers: It is often unclear if family caregivers are permissible; this restriction is not explicitly stated in either the Optum or TriWest handbooks. Additionally, some states have their own restrictions on family caregivers. If you're considering hiring a family caregiver and the guidelines aren't clear, obtain explicit written permission from the case manager.

4.5Re-credentialing

Providers who do not diligently monitor their contract terms may face coverage lapses and payment delays.

  • Three Year Term: If you're serving Veterans through the VACCN, you need to get re-credentialed every three years.
  • Re-credentialing Responsibility: It's up to you to keep track of your contract dates. It is recommended to keep an eye on your email 60 days (about 2 months) prior to your contract expiration date for any communications on the matter.

4.6Staying On Top of Alerts and Advisories

Staying informed requires reliable information sources - ideally, ones that deliver real-time updates without the noise.

Where to Find Official VA Bulletins and TPA Announcements

Recommended Subscription Lists & Resources

Set up a weekly review process within your team or assign one staff member to monitor updates, summarize changes, and distribute internal briefs.

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