Final Audit Plans

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Final Audit Plans

Audit Plan Name

Objective

Scope and Methodolgy

Public Comments (if applicable)

Preliminary Audit Plan Posted for Public Comment (date)

Final Audit Plan Posted (date)

VA Community Care (VACC) claims reimbursed through the Electronic Claims Adjudication Management System (eCAMS), Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) reimbursed through ClaimsXM and Spina Bifida (SB) Program of the Department of Veterans Affairs reimbursed through ClaimsXM for Fiscal Years (FY) 2022 and 2023.

Cotiviti will review paid claims for VA Community Care Non-Network Claims (CCCNNC) paid by VA through the Electronic Claims Adjudication Management System (eCAMS), paid claims for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) paid by VA through ClaimsXM and paid claims for the Spina Bifida (SB) Program of the Department of Veterans Affairs paid by VA through ClaimsXM.

Cotiviti will review claims paid by VA in Fiscal Year 2022 (10/1/2021-09/30/2022), and Fiscal Year 2023 (10/01/2022-09/30/2023).

The review will include claims paid under the following authorities:
CCCNNC
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)
CHAMPVA
38 U.S.C. § 1781 (Medical Care for survivors and dependents of certain veterans)
38 C.F.R § 17.270-17.278 (Civilian Health and Medical Program of the Department of Veterans Affairs)
SB
38 C.F.R § 17.900-17.905 (Health Care Benefits for Certain Children of Vietnam Veterans and Veterans with Covered Service in Korea—Spina Bifida and Covered Birth Defects)

Criteria for this audit is based on the following questions:
1. Was the care rendered under § 1703 in compliance with the authorization/referral?
2. Was the care rendered under 38 U.S.C. § 1781 and 38 C.F.R § 17.270-17.278 in compliance with the authorization/referral?
3. Was the care rendered under 38 C.F.R § 17.900-17.905 in compliance with the authorization/referral?
4. Was the appropriate rate reimbursed based on the methodology under applicable VA authorities?
5. Do the medical records support the billed services?

Information from the following sources will be used to determine the accuracy of each payment:
1. Authorization/referral for services.
2. Paid claim data.
3. 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:
1. This audit will not include FY22, FY23 claims rendered under the Patient Centered Community Care (PC3)/CHOICE or Community Care Network (CCN) contracts.
2. Claims specifically excluded from the scope of the contract:
a. Claims paid to the Department of Defense
b. Claims paid by VA for care furnished outside of the United States and its territories
c. Claims paid for State Home Per Diem Program
d. Claims paid related to domiciliary care
f. Claims paid for dental
g. Claims paid for adult day healthcare
h. Claims paid for bowel and bladder care
i. Claims currently under investigation by the VA for potential fraud, waste, and abuse
j. Claims included in equitable relief
k. Claims in prepayment review
l. Claims paid directly to Veterans
m. Any claim or claim type specifically sequestered by the VA
n. Claims paid directly to a beneficiary
o. Claims where CHAMPVA was secondary payer
p. Claims for travel other than ambulance associated with medical care
q. Pharmacy claims including "Meds by Mail"

1. Comment - Related to structure of how portal is accessed.
Response: Cotiviti has improved the portal registration process by removing the provider number requirement. The KBA (knowledge-based authentication) registration process now utilizes the NPI along with claims and demographic information to qualify a provider for portal credentials. For assistance with the KBA process, please review Cotiviti’s Portal User Guide on the home page or contact Cotiviti’s Provider Relations Team, 855-287-1667 Monday – Friday between the hours of 6:00 a.m. – 5:00 p.m. PST.
This change does not impact providers who were already registered, you may continue to access the portal using your email login credentials.

2. Comment: What kinds of hospitals will be included in these categories? Will it just be general short-term acute care hospitals?
Response: Cotiviti will review all paid inpatient claims for VA Community Care Non-Network Claims (CCNNC) paid by VA through the Electronic Claims Adjudication Management System (eCAMS). Cotiviti will also review claims for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), which is paid under 38 U.S.C. 1781 and the Spina Bifida Health Care Benefits Program under 38 U.S.C. 1802, 1803, 1821 and 1822.

3. Comment: When will the preliminary audit plan on the Cotiviti web site be finalized?
Response: The preliminary audit plan will be open for public review and commentary for a minimum of 30 calendar days. Upon completion of the 30-day posting period, VA and Cotiviti will review comments and make appropriate adjustments before the plan is finalized. The final audit plans will be posted to Cotiviti’s public website before the audit begins, estimated to be no later than Monday May 6, 2024.

4. Comment: One of the listed sources of paid claims is “Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) paid by VA through Oracle.” Is Oracle the system that health care providers use to submit claims electronically to CHAMPVA?
Response: Oracle is not our claims processing system. CHAMPVA claims are currently processed through a commercial system named ClaimsXM.

5. Comment: One of the listed exclusions is “Claims where CHAMPVA was secondary payer.” Does this mean that claims where Medicare is primary will not be included in this review, even if Medicare denied some or all of the claimed payment?
Response: This is correct. All claims where CHAMPVA was a secondary payer are excluded from the audit.

6. Comment: It appears that the Final Audit Plans and FAQ tabs on the Cotiviti web site include information that only relates to the former audit of FY 2018 and FY 2019 claims. Is that correct? Will these tabs be updated for the upcoming FYs 2022-2023 audits?
Response: Once the 30-day comment period has elapsed and VA has approved the audit, then Cotiviti will post the audit plan to the final Audit Plan tab.

03/08/2024

05/03/2024

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

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).

Addendum, Cotiviti will also review paid inpatient claims for VA Community Care (VACC), (formerly known as Non-VA Care or Fee Basis) paid by VA through the Electronic Claims Adjudication Management System Healthcare Engine (eCAMS HCE).

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:
a. Claims paid to the Department of Defense
b. Claims paid by VA for care furnished outside of the United States and its territories
c. Claims paid for State Home Per Diem Program
d. Claims paid related to domiciliary care
e. Claims paid for contract nursing home care
f. Claims paid for dental
g. Claims paid for adult day healthcare
h. Claims paid for bowel and bladder care
i. Claims currently under investigation by the VA for potential fraud, waste, and abuse
j. Claims included in equitable relief
k. Claims in prepayment review
l. Claims paid directly to Veterans
m. Any claim or claim type specifically sequestered by the VA

Cotiviti received a total of 20 public comments

Three providers inquired if the scope of the audit includes inpatient only or both inpatient and outpatient claims.
Response: The scope of the audit includes 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).

Two providers inquired if there is a provider portal.
Response: Yes, Once the Provider Portal is live, providers will be able to log in using an authentication process and will be able to view medical records request letters, medical record tracking, dispute and appeal dispositions.

One provider requested additional information about the audit process and scope for agencies that contract with the VA in different states.
Response: The scope of the audit includes 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). The audit will review all claims paid in a given fiscal year by the provider tax identification number. If the provider has multiple locations with different tax identification numbers, each tax identification number will receive notices regarding claims audit when appropriate.

One provider requested a delay on the audit for contract nursing homes.
Response: As outlined in the scope and methodology, claims for contract nursing home care are exluded from the scope of this contract.

Ten providers sumbitted claim specific inquiries which have been referred to the VA for follow-up.

The remaining 3 comments were unrelated to the recovery audit or failed to provide any narrative to be addressed.

01/03/2022

03/17/2022

Final Audit Plans

Session Expiring!