VA RAC

CMS RAC



Preliminary Audit Plan

VA Community Care (VACC) Inpatient Claims Reimbursed Through the Fee Basis Claim System (FBCS) for Fiscal Years 2018 and 2019

Objective: Cotiviti will review paid inpatient claims for VA Community Care (VACC) (formerly known as Non-VA Care or Fee Basis) paid by VA through the Fee Basis Claims System (FBCS).

Scope and Methodology: Cotiviti will review inpatient claims paid by the VA in Fiscal Year 2018 (10/1/2017-09/30/2018) and Fiscal Year 2019 (10/01/2018-09/30/2019). Findings will be aggregated by provider Tax Identification Number (TIN) and by Fiscal Year.

The review will include inpatient claims paid under the following authorities:

  • 38 U.S.C. § 1703 (authorized care)
  • 38 U.S.C. § 1728 (service connected unauthorized care)
  • 38 U.S.C. § 1725 (non-service connected emergency care)

Criteria for this audit is based on the following questions:

  • Was the care rendered under § 1703 in compliance with the authorization/referral?
  • Was appropriate rate reimbursed based on the methodology under applicable VA authorities?
  • Do the medical records support the Diagnostic Related Group (DRG) billed for the services?

Information from the following sources will be used to determine the accuracy of each payment:

  • Authorization/referral for services.
  • Submitted Claim.
  • VA Non-VA Hospital (NVH) DRG pricing.
  • Approved days documentation (applicable for inpatient claims paid at per diem rate, rather than full DRG).
  • Medical records.

The following assumption will apply to this audit:

  • Payment by the VA for the reviewed claims is determinative of the Veteran’s eligibility for the care; therefore, Cotiviti will not review Veteran eligibility.

Exclusions:

  • All claims with dates of service prior to 10/1/2017 will be excluded from the audit.
  • This audit will not include FY18 or FY19 inpatient claims rendered under the Patient Centered Community Care (PC3)/CHOICE or Community Care Network (CCN) contracts.
  • Claims specifically excluded from the scope of the contract:
    • Claims paid to the Department of Defense
    • Claims paid by VA for care furnished outside of the United States and its territories
    • Claims paid for State Home Per Diem Program
    • Claims paid related to domiciliary care
    • Claims paid for contract nursing home care
    • Claims paid for dental
    • Claims paid for adult day healthcare
    • Claims paid for bowel and bladder care
    • Claims currently under investigation by the VA for potential fraud, waste, and abuse
    • Claims included in equitable relief
    • Claims in prepayment review
    • Claims paid directly to Veterans
    • Any claim or claim type specifically sequestered by the VA

Should you have questions on the recovery audit unrelated to the preliminary Audit Plan, please review our FAQ document or contact Cotiviti Provider Services at 855-287-1667 Monday – Friday between the hours or 9:00 a.m. – 8:00 p.m. EST.

For questions related to Veteran Care in the Community (VACC) claims payment status, contact 877-881-7618, Monday – Friday, between the hours of 8:00 am - 9:00 pm EST. For questions related to CHAMPVA claims payment status contact 800-733-8387, Monday – Friday, between the hours of 8:05 am - 7:30 pm EST.

Contact us today about VA RAC to submit your questions or comments regarding the preliminary audit plan