VETERANS AFFAIRS – PATIENT CENTERED COMMUNITY CARE “PC3” & VETERANS

CHOICE PROGRAM “VCP”

CyberKnife® Robotic Radiosurgery System

CYBERKNIFE® COALITION (CKC)

VA OPPORTUNITY

• 22 Million Veterans registered in VA Health Care System

• 14 Million Male Veterans over 40

• US Statistics - 1 in 7 will be diagnosed with Prostate Cancer

– Veterans are 1 in 5

• Even conservative estimates place the cost of lung cancer to the VA at over $1 Billion a year.

• 2014 Senators Bernie Sanders & John McCain sponsored & implemented Temporary VA Choice Program

– ~$10 Billion over 3 years allocated to 2 contractors (TriWest Healthcare Alliance, & Health Net Federal Services)

– Veterans qualification – 30 days to an appointment, 40 miles of travel, or VA does not have the technology to treat the Veteran

– VA Primary Care Physician makes the referral outside the VA to qualified medical providers

• Senator McCain recently introduced Permanent VA Choice Card Act to make the current three-year pilot program for the VA Choice Card permanent, removing the 40-mile limit & making all Veterans eligible.

• Patient of Phoenix Veterans Affairs Health Center since 2011

• Requested annual Prostate Screening (2011 - 2015) PSA & DRE

– PSA’s 2.1, 2.5, 2.6, 5.2, 14.6

– In 2014 never notified of the 5.2 PSA reading – VA sent a letter in the US Mail (lost), but no calls, email notice, or attempt to notify.

• October 16, 2015 – requested a Prostate Screen - results October 23.

– Results 14.6 PSA - Urology follow up scheduled 29 days later (to meet the 30 day VA scheduling requirement)

– Presented myself at Urology scheduling & made an appointment the following day – October 24

• VA Urologist - wait 6 months then another PSA / Prostate Screen

• Contacted Dr. Sandra Vermeulen & Dr. Robert Meier @ Swedish CyberKnife

• Biopsy immediately scheduled in Phoenix, results December 9, 2015 – “You’ve Got Cancer” – Gleason 7 (4+3)

• Treated by Dr. Bob Meier - CyberKnife / completed treatments Dec 31, 2015.

• 90 Day check up shows PSA 4.2 and NO SIDE EFFECTS.

MIKE CROSBY, CDR USN RET.

VETERAN & PROSTATE CANCER SURVIVOR

• Veteran Choice Program is part of the Veterans Access, Choice, and Accountability Act of 2014 (VACAA)

• TriWest Healthcare Alliance & Health Net Federal Services LLC have been awarded five year contracts by the Department of Veterans Affairs (VA) to administer the VA Patient-Centered Community Care (VA “PC3”) ~ $10 B

• Access / Registration with the Program is based on your centers location.

• Providers interested in participating must establish a contract with one of the contractors, Health Net Federal, or TriWest Healthcare Alliance.

VETERANS AFFAIRS – CHOICE PROGRAM

Regions 3, 5 &6 South & West

Coast $4.3 Billion

Regions 1, 2 & 4 North & East

Coast $4.9 Billion

Providers:

• Must Accept Medicare rates.

• Must Meet all Medicare Conditions of Participation and Conditions for Coverage.

• Must be in compliance with all applicable federal and state regulatory requirements.

• Must have a full, current, and unrestricted license in the state where the service(s) are delivered.

• Must have same or similar credentials as VA staff.

• Must be able to submit a copy of the medical records to the contractor (TriWest or Health Net) for medical care and services provided to Veterans for inclusion in the VA electronic record.

• Those listed on the Centers for Medicare and Medicaid Services (CMS) exclusionary list are prohibited from participating.

VA – PCCC & CHOICE PROGRAM PROVIDER

PC3 VS. VETERANS CHOICE

Patient-Centered Community Care (PC3)

Veterans Choice Program (VCP)

Plan Description

A program designed to enhance access to health care by allowing VA medical centers to refer Veterans to a quality provider network closer to a Veteran’s home.

A program for Veterans that allows them to seek care from community providers if the Veteran faces wait times longer than 30 days for a specific service from a VA medical center, or when a VA medical facility is not easily accessible (>40 miles) from their home.

Automatically enrolled if you join PC3

Referrals The VA medical center sends a care request to TriWest or Health Net and the network provider subsequently receives an authorization for care from TriWest or Health Net. TriWest or Health Net calls the provider to schedule the appointment on behalf of the Veteran.

The Veteran calls TriWest or Health Net to learn if he or she is eligible for the VCP. If so, the Veteran may request to see a certain provider, or TriWest/Health Net may find a provider for the Veteran. TriWest/Health Net sends an authorization to the provider and schedules the appointment on behalf of the Veteran. For Veterans who are on a 30-day wait list, the provider will also receive clinical/consult information from a VA medical center. For Veterans who live at least 40 miles from a VA medical center, only the TriWest/HealthNet authorization is provided.

PC3 VS. VETERANS CHOICE

Patient-Centered Community Care (PC3)

Veterans Choice Program (VCP)

Other Health Insurance

Other Health Insurance (OHI) is not relevant.

TriWest/Health Net will notify the provider if Commercial/private OHI should be billed. When the provider is notified, the private health insurance is the primary payor and TriWest/Health Net pays on behalf of VA secondarily. Medicare, Medicaid, and TRICARE are not considered as OHI for the purposes of the Veterans Choice Program (VCP). These plans are not billed by the VCP provider and the Veteran is not responsible for any Medicare, Medicaid or TRICARE cost-shares under the Veterans Choice Program.

Co-Pays Provider is not responsible for the collection of any co-payments. All allowable charges are paid by TriWest/Health Net

If commercial OHI is present, provider should follow the co-payment requirements of the OHI carrier.

PC3 VS. VETERANS CHOICE

Patient-Centered Community Care (PC3)

Veterans Choice Program (VCP)

Medical Documentation

Medical documentation must be submitted to TriWest/Health Net PRIOR to payment of any claim.

Medical documentation must be submitted to TriWest/Health Net to retain VA continuity of care.

Claims Submission

After sending medical documentation to TriWest, provider submits claim to Wisconsin Physicians Service (WPS), TriWest’s claims processing partner. Network provider is paid according to terms in provider contract. Health Net utilizes Availity for processing claims

After sending medical documentation to TriWest, provider submits claim to WPS, TriWest’s claims processing partner. The VCP provider is paid according to his or her VCP agreement. Health Net processes all claims for VCP.

Secondary Authorization Requests (SAR)

SARs must be submitted to TriWest/Health Net via fax for any services beyond what has been authorized. Authorizations and SARs will be communicated and displayed on TriWest’s/Health Nets Secure Provider Portal . A program indicator for PC3 will display on the summary page.

SARs must be submitted to TriWest /Health Net via fax for any services beyond what has been authorized. Authorizations and SARs will be communicated and displayed on TriWest’s/Health Net’s Secure Provider Portals. A program indicator for the VCP will display on the summary page.

• Health Net Federal Services contract covers Regions 1, 2 and 4, which encompass all or portions of 37 states, including the District of Columbia, Puerto Rico and the U.S. Virgin Islands.

• All Patient – Centered Community Care (PC3) providers are automatically eligible to participate in the Choice Program.

• Contact Health Net t using the information listed below.

• Health Net:

– Hours: 6:00am — 7:00pm EST Monday through Friday, excluding federal holidays

– Provider Customer Services: 1-866-606-8198

– Email: HNFSProviderRelations@Healthnet.com

– Website: www.hnfs.com

HEALTHNET FEDERAL SERVICES – NORTH & EAST

Go to - www.hnfs.com Select “Options for Providers”

RECOMMEND THE PCCC NETWORK

JOINING THE PCCC NETWORK

DOWNLOAD OR OPEN THE FORM

FILL IN THE APPROPRIATE DATA

Radiation Oncology / CyberKnife is considered “other” Insure Contracting

Information is accurate (its how you get paid)

Most likely you provide Radiology & Radiation Oncology Services so fill out both additional forms

You can submit these forms electronically, however we recommend printing a copy as well.

RADIATION ONCOLOGY FORM

PROVIDER SPECIFIC INFORMATION FORM

• TriWest Health Alliance contract covers Regions

3, 5 and 6 which encompass all or portions of

28 states, as well as American Samoa, Guam

and the Northern Mariana Islands.

• All Patient – Centered Community Care (PC3)

providers are automatically eligible to participate

in the Choice Program.

• Contact TriWest using the information listed

below.

• TriWest:

– Hours: 8:00am — 10:00pm EST, Monday

through Friday, excluding federal holidays

– Provider Services Contracting: 1-866-284-

3743

– Email: TriWestDirectContracting@triwest.com

– Website: joinournetwork.triwest.com/

TRIWEST HEALTH ALLIANCE – SOUTH & WEST

TRIWEST - HTTPS://VAPCCC.TRIWEST.COM

RECOMMEND JOINING THE PC3 NETWORK

JOIN THE NETWORK

SELECT VAPC3 NETWORK

All the additional forms and information are provided after you submit this initial Provider Registration form.

• Significant opportunity exists to provide Veterans with quality care & treatment of serious disease (Prostate Cancer / Lung Cancer / Brain Tumors, etc.)

• Register your CyberKnife centers with the Veterans Affairs Patient Centered Community Care (PC3) Programs – This includes the “Choice Program”

• NEXT STEPS - When you are registered and approved to accept patients we encourage you to get involved with our upcoming awareness campaigns.

– Starting with Prostate Cancer Education & Awareness

– Efforts to support Veterans Affairs Healthcare Reform

BOTTOM LINE

Polling questions on Webex:

1) Does your center currently treat VA Patients?

2) Based on what you learned today, would you be interested in signing up for the Choice Program?

• Yes

• No

• Already signed up

3) What are your challenges in treating VA patients (choose all that apply)?

• Patient Awareness

• Inability to access VA Network

• Competition with other centers

4) Would you be interested in working with the CKC and Accuray on an outreach program to the VA?

FEEDBACK AND NEXT STEPS

APPENDIX