by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Nov 20th, 2019
How does the VA determine charges billed to third party payers for veterans with private health insurance?
According to the VA, "38 C.F.R 17.101 stipulates the basic methodology by which VA bills third party insurance carriers. In order to generate a charge for medical services, VA establishes reasonable charges for five categories of charges:
- Inpatient facility
- Skilled nursing facility (SNF)/sub-acute inpatient facility
- Outpatient facility
- Nonphysician providers
Reasonable charges are developed nationally and then adjusted locally by each VA medical center based on their Geographical Area Adjustment Factor (GAAF). Billing for inpatient facilities and skilled nursing facilities are on a per diem basis. For inpatient facility charges, the per diem charges vary by the treated condition as classified by Medicare Severity Diagnosis Related Groups (MS-DRG) codes. Billing for outpatient facility and provider charges vary by procedure performed as classified by current procedural terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) Level II codes. Data for calculating actual charge amounts are published in a notice within the Federal Register or can be viewed on the VHA OCC website."
Find-A-Code offers COST BASED pricing used for Non-Service-Related reimbursed fees/Third Party Payers and INTER-AGENCY rates from VA Beneficiaries.
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.