The Veterans Access, Choice, and Accountability Act, enacted in August, marked a significant shift in how veterans access healthcare. This legislation mandated the Department of Veterans Affairs (VA) to establish pathways for veterans to receive necessary medical care outside of the traditional VA system under specific circumstances. This pivotal law addressed critical capacity issues within VA facilities, aiming to ensure timely and accessible treatment for all veterans by leveraging resources within the broader community healthcare network. This initiative led to the creation of the Patient Centered Community Care Program, designed to bridge gaps in care and enhance the healthcare experience for veterans.
What is the Patient Centered Community Care Program?
The Patient Centered Community Care program (PCCC) was established by the VA to expand healthcare access for veterans, particularly for services like mental health and substance use disorder (SUD) treatment. This program is specifically designed to offer care outside of VA facilities when the VA system’s capacity is limited. Eligibility for the PCCC program is not universal; it is contingent upon specific circumstances at the veteran’s local VA Medical Center. Veterans may qualify for community care under the Patient Centered Community Care program if their local VA facility faces any of the following challenges:
- Lack of Specialist Availability: When the local VA center does not have specialists available in the required healthcare area.
- Extended Appointment Wait Times: If the wait time for a scheduled appointment exceeds 30 days.
- Geographic Distance Barrier: When the veteran resides more than 40 miles from the closest VA facility.
These criteria ensure that the Patient Centered Community Care program effectively supports veterans who might otherwise face significant barriers to accessing timely and appropriate healthcare within the VA system.
Who is Eligible to Provide Behavioral Health Services Under the PCCC Program?
The Patient Centered Community Care program carefully defines the types of behavioral health professionals authorized to provide services to veterans. Currently, the following licensed professionals are eligible for reimbursement under the PCCC program for delivering behavioral health services:
- Psychiatrists
- Clinical Nurse Practitioners
- Psychologists
- Licensed Clinical Social Workers
While the VA has expressed openness to potentially broadening this list in the future, it’s important to note that, at present, reimbursement is strictly limited to services provided by these enumerated professionals within the Patient Centered Community Care program. Furthermore, providers offering Evidence-Based Therapies (EBTs) are required to demonstrate specialized training and substantial experience in administering these specific therapies to ensure the highest quality of care for veterans.
How Does the Patient Centered Community Care Program Function?
Navigating the Patient Centered Community Care program involves several key steps for behavioral health providers aiming to offer care to eligible veterans. HealthNet, a designated VA contractor, plays a crucial role in managing various operational aspects of the PCCC program. Here is a detailed overview of the process:
Becoming a Provider within the PCCC Network
- Provider Participation Agreement: Providers initiate the process by signing a participation agreement with the VA. This step is facilitated through HealthNet.
- Credentialing with the VA: Providers must undergo a credentialing process with the VA. A credentialing application, accessible via HealthNet and integrated with CAQH (Council for Affordable Quality Healthcare), is used for this purpose.
- On-boarding Packet: Upon successful credentialing, providers receive an on-boarding packet directly from the VA. This packet contains essential contact information, outlines program expectations, includes necessary forms, and provides other valuable resources to aid providers in program participation.
Identifying and Engaging Qualified Veterans
- Veteran Eligibility Determination: The VA first identifies veterans who meet the eligibility criteria for receiving community-based services under the Patient Centered Community Care program.
- Provider Matching: Based on the veteran’s specific clinical needs and geographic location, the VA identifies a suitable community provider.
- Initial Appointment Scheduling: HealthNet then contacts the selected provider to schedule the veteran’s initial appointment. Crucially, appointments must be scheduled within 14 days of contact, and veterans should experience minimal wait times, ideally no more than 20 minutes in the waiting room. Subsequent appointments are managed directly by the veteran and the provider.
- Provider Notification Packet: Once the initial appointment is confirmed, HealthNet faxes a Provider Notification Packet to the provider. This packet is critical as it details the services authorized under the Patient Centered Community Care program, including the approved date range and the number of authorized visits. Providers will only receive reimbursement for services that are explicitly pre-authorized.
- Veteran Authorization Request: It is important to note that the veteran must formally request authorization for services from the VA. Providers cannot initiate this authorization request on behalf of the veteran.
Treating Veterans and Managing Ongoing Care
- Requesting Additional Services: Should a veteran require services beyond the scope of the initial authorization, the provider must submit an Additional Sessions Request Form. This request must be submitted before the initially authorized sessions are completed. If all authorized sessions have been utilized, the veteran must contact the VA directly to seek a new authorization, as providers are not permitted to request this on their behalf.
Medical Records and Claims Payment Procedures
- Medical Documentation Submission: Timely submission of medical documentation is essential for claim processing. Providers are required to fax medical documentation to HealthNet. VA guidelines specify that “Medical documents are expected within 10 days after the first visit and within 10 days after the last visit.” HealthNet representatives have clarified that submitting medical documents within 14 days of service provision is acceptable.
- Claims Submission: Providers can choose to submit claims either via paper to HealthNet or electronically through Emdeon, a healthcare clearinghouse.
- Payment Processing: The VA processes payments to providers via check, typically within 30 days of claim receipt, provided that the necessary medical documentation has also been submitted. The VA is actively developing an electronic funds transfer (EFT) system to streamline payments in the future, although this is not yet available.
Reimbursement Rates Under the PCCC Program
Reimbursement rates for services provided under the Patient Centered Community Care program are calculated based on the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS). Specific rates are set at a percentage of the CMS maximum allowable charges, differentiated by provider license level:
- 85% of CMS Maximum Allowable: This rate applies to Licensed Clinical Social Workers, Psychiatric Nurse Practitioners, and Psychologists.
- 90% of CMS Maximum Allowable: Psychiatrists receive a slightly higher reimbursement rate.
These rates ensure that providers are fairly compensated for delivering essential behavioral health services to veterans through the PCCC program.
Other Important Considerations for PCCC Providers
- Wrap-Around Services: If a veteran requires additional services not covered under the initial service authorization, the VA is responsible for providing referrals to community resources for these supplementary services.
- Veteran Identification: Veterans participating in the Patient Centered Community Care program will not present a traditional VA healthcare ID card when seeking services from community providers.
- Copayments and Costs: Veterans utilizing the PCCC program do not incur any copayments, deductibles, or cost-sharing obligations for authorized services.
- Missed Appointments: Neither veterans, the VA, nor HealthNet can be billed for missed appointments or “no-shows.”
How to Initiate the Process to Become a PCCC Provider
To begin the process of becoming a participating provider in the Patient Centered Community Care program, interested professionals should send an email request for a provider agreement to Guss Riddles at HealthNet (the VA’s contractor for the PCCC program) at [email protected]. Please ensure the subject line of the email clearly states “PCCC Contract Request.”
In the body of the email, please include the following essential information:
- Name of the individual provider or the official name of the group/practice
- Tax ID number or Social Security Number (SSN)
- Practice address (if multiple locations, please provide the main/corporate address)
- Phone number for the individual/group/practice
- Email address (if different from the sender’s email address)
Upon sending your email, you should expect to receive a credentialing application and participation agreement at the provided email address within approximately 5 business days. The VA’s credentialing process typically takes between 30 to 45 days to complete. HealthNet utilizes CAQH for the credentialing process, which may streamline aspects of the application for providers already registered with CAQH.
For more comprehensive details about the Patient Centered Community Care program, please refer to the detailed document available here. This resource provides extensive information and can further assist providers in understanding and participating in this crucial program designed to support our nation’s veterans.
