VA Medical Centers
Internal Control Weaknesses Impair Third-Party Collections Gao ID: GAO-04-967T July 21, 2004In the face of growing demand for veterans' health care, GAO and the Department of Veterans Affairs Office of Inspector General (OIG) have raised concerns about the Veterans Health Administration's (VHA) ability to maximize its third-party collections to supplement its medical care appropriation. GAO has testified that inadequate patient intake procedures, insufficient documentation by physicians, a shortage of qualified billing coders, and insufficient automation diminished VA's collections. In turn, the OIG reported that VA missed opportunities to bill, had billing backlogs, and did inadequate follow-up on bills. While VA has made improvements in these areas, GAO was asked to review internal control activities over third-party billings and collections at selected medical centers to assess whether they were designed and implemented effectively.
VA has continued to take actions to reduce billing times and increase third-party collections. VA reported that its collections of third-party payments increased from $540 million in fiscal year 2001 to $804 million in fiscal year 2003. However, at the three medical centers visited, GAO found continuing weaknesses in the billings and collections processes that impair VA's ability to maximize the amount of dollars paid by third-party insurance companies. For example, the three medical centers did not always bill insurance companies in a timely manner. Medical center officials stated that inability to verify and update patients' third-party insurance, inadequate documentation to support billings, manual processes and workload continued to affect billing timeliness. The detailed audit work at the three facilities GAO visited also revealed inconsistent compliance with follow-up procedures for collections. For example, collections were not always pursued in a timely manner and partial payments were accepted as payments in full, particularly for Medicare secondary insurance companies, rather than pursuing additional collections. VA's current Revenue Action Plan (Plan) includes 16 actions designed to increase collections by improving and standardizing collections processes. Several of these actions are aimed at reducing billing times and backlogs. Specifically, medical centers are updating and verifying patients' insurance information and improving health care provider documentation. Further, hiring contractors to code and bill old cases is reducing backlogs. In addition to actions taken, VA has several other initiatives underway. For example, VA is taking action to enable Medicare secondary insurance companies to determine the correct reimbursement amount, which will strengthen VA's position to follow up on partial payments that it deems incorrect. Although implementation of the Plan could improve VA's operations and increase collections, many of its actions will not be completed until at least fiscal year 2005. As a result, it is too early to determine the extent to which actions in the Plan will address operational problems and increase collections.
GAO-04-967T, VA Medical Centers: Internal Control Weaknesses Impair Third-Party Collections
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Testimony:
Before the Subcommittee on Oversight and Investigations, Committee on
Veterans' Affairs, House of Representatives:
For Release on Delivery Expected at 10: 00 a.m. EDT Wednesday, July 21,
2004:
VA Medical Centers:
Internal Control Weaknessess Impair Third-Party Collections:
Statement of McCoy Williams, Director, Financial Management and
Assurance:
GAO-04-967T:
GAO Highlights:
Highlights of GAO-04-967T, a testimony before the Subcommittee on
Oversight and Investigations, Committee on Veterans‘ Affairs, House of
Representatives
Why GAO Did This Study:
In the face of growing demand for veterans‘ health care, GAO and the
Department of Veterans Affairs Office of Inspector General (OIG) have
raised concerns about the Veterans Health Administration‘s (VHA)
ability to maximize its third-party collections to supplement its
medical care appropriation. GAO has testified that inadequate patient
intake procedures, insufficient documentation by physicians, a shortage
of qualified billing coders, and insufficient automation diminished
VA‘s collections. In turn, the OIG reported that VA missed
opportunities to bill, had billing backlogs, and did inadequate
follow-up on bills. While VA has made improvements in these areas, GAO
was asked to review internal control activities over third-party
billings and collections at selected medical centers to assess whether
they were designed and implemented effectively.
GAO‘s report on this issue, GAO-04-739, released concurrently with this
testimony, makes five recommendations to augment actions already
underway to facilitate more timely billings and improve collection
operations.
What GAO Found:
VA has continued to take actions to reduce billing times and increase
third- party collections. VA reported that its collections of
third-party payments increased from $540 million in fiscal year 2001 to
$804 million in fiscal year 2003. However, at the three medical
centers visited, GAO found continuing weaknesses in the billings and
collections processes that impair VA‘s ability to maximize the amount
of dollars paid by third-party insurance companies. For example, the
three medical centers did not always bill insurance companies in a
timely manner. Medical center officials stated that inability to
verify and update patients‘ third-party insurance, inadequate
documentation to support billings, manual processes and workload
continued to affect billing timeliness.
The detailed audit work at the three facilities GAO visited also
revealed inconsistent compliance with follow-up procedures for
collections. For example, collections were not always pursued in a
timely manner and partial payments were accepted as payments in full,
particularly for Medicare secondary insurance companies, rather than
pursuing additional collections.
VA‘s current Revenue Action Plan (Plan) includes 16 actions designed to
increase collections by improving and standardizing collections
processes. Several of these actions are aimed at reducing billing
times and backlogs. Specifically, medical centers are updating and
verifying patients‘ insurance information and improving health care
provider documentation. Further, hiring contractors to code and bill
old cases is reducing backlogs. In addition to actions taken, VA has
several other initiatives underway. For example, VA is taking action to
enable Medicare secondary insurance companies to determine the correct
reimbursement amount, which will strengthen VA‘s position to follow up
on partial payments that it deems incorrect. Although implementation
of the Plan could improve VA‘s operations and increase collections,
many of its actions will not be completed until at least fiscal year
2005. As a result, it is too early to determine the extent to which
actions in the Plan will address operational problems and increase
collections.
www.gao.gov/cgi-bin/getrpt?GAO-04-967T.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact McCoy Williams at
(202) 512-6906 or williamsm1@gao.gov.
[End of section]
Mr. Chairman:
I am pleased to be here today to discuss internal controls over VHA's
third-party billings and collections.
First, I would like to recognize VA's continued efforts to increase
third-party collections, which have increased from $540 million in
fiscal year 2001 to $804 million in fiscal year 2003. However, in the
face of growing demand for veterans' health care, GAO and the
Department of Veterans Affairs Office of Inspector General have raised
concerns about the Veterans Health Administration's (VHA) ability to
maximize its third-party collections to supplement its medical care
appropriation. In September 2001, we testified that problems in VA's
collection operations--such as inadequate patient intake procedures to
gather insurance information, insufficient physician documentation of
the specific care provided, a shortage of qualified coders, and
insufficient automation--diminished VA's collections.[Footnote 1] In
February 2002, the VA OIG reported that VA missed billing
opportunities, had billing backlogs, and did inadequate follow-up on
accounts receivable in fiscal years 2000 and 2001.[Footnote 2] In May
2003 we testified that VA had made improvements in these areas but that
operational problems, such as unpaid accounts receivable, missed
billing opportunities, and billing backlogs continued to limit the
amount VA collects.[Footnote 3]
In conjunction with this revenue-enhancing responsibility, you asked us
to review internal control activities over third-party billings and
collections at selected VHA medical centers to assess whether internal
controls are designed and implemented effectively. Our report on this
issue is being released today at this hearing.[Footnote 4]
You also asked that we review internal control activities in three
areas of operation at selected VHA medical centers--accountability over
personal property, drugs returned for credit, and part-time physician
time and attendance. That report is also being issued today. At your
request we also reviewed VHA's purchase card program for fiscal year
2002 and our report was issued June 7, 2004.
In my testimony today, I will discuss continuing weaknesses in the
billings and collections processes that impair VA's ability to maximize
the amount of dollars paid by third-party insurance companies. The
scope of our work, which was performed from March 2004 through June
2004 in accordance with generally accepted government auditing
standards, is detailed in the report being released today.
Heads of agencies are required to establish systems of internal control
consistent with our Standards for Internal Control in the Federal
Government.[Footnote 5] Effective internal controls are the first line
of defense in safeguarding assets and in preventing and detecting
fraud. In addition, they help to ensure that actions are taken to
address risks and are an integral part of an entity's accountability
for the stewardship of government resources.
As I will discuss in my testimony, we found at the three medical
centers visited that internal controls were not designed to provide
reasonable assurance that medical centers billed insurance companies in
a timely manner or consistently complied with follow-up procedures for
collections. We focused on billing transactions that occurred in the
first quarter of fiscal year 2004 at the Cincinnati, OH; Tampa, FL; and
Washington, D.C. medical centers.
I will first discuss the results of our review over billing timeliness.
Then I will discuss control weaknesses in collection activities that
hamper VA's ability to collect all monies due to the agency from third-
party insurance companies for veterans' care. And finally, I will
highlight some of VA's initiatives to increase collections from third-
party insurance companies.
Operational Enhancements Could Improve Timeliness of Billings:
While VA reported that it has decreased the average number of days it
takes to bill for patient services, we found that medical centers could
further improve billing timeliness by continuing to address operational
problems that slow down the process. These operational problems
include, among other things, delays in verifying and updating patient
insurance information, incomplete or inaccurate documentation of
patient care by health care providers, manual intervention, and
workload. VA's billing process cuts across four functional areas, from
patient intake, to medical documentation of treatment, to coding the
treatment accurately prior to billing. Each phase of the billing
process is dependent on the completeness and accuracy of information
collected in the prior phases. Breakdowns occurring during any part of
the process can affect the timeliness of billings.
VA's policies and procedures do not specify the number of days for a
bill to be issued once health care services are rendered. In fiscal
year 2003, VA's Business Oversight Board established performance
goals[Footnote 6] that were incorporated into the network and medical
directors' performance contracts. The goal for sending a bill within a
set number of days was reduced periodically during fiscal year 2004.
During the time of our review, the performance goal for billing third
party insurance companies was an average of 50 days from the date of
patient discharge. As of the end of the first quarter of fiscal year
2004, the average days to bill third parties for Tampa, Washington,
D.C. and Cincinnati were 73, 69, and 44 respectively.
At each of the three medical centers visited, we made a non-
representative selection of 30 patients billed during the first quarter
of fiscal year 2004. In evaluating the timeliness of billing, we used
the performance standard then in effect of 50 days after patient
discharge. We recognize that the cumulative billing times for the 90
cases selected do not represent the average days to bill, which VHA
uses to measure each medical center's performance. However, cases
billed more than 50 days after patient discharge are illustrative of
problematic issues that can delay billings. For the 90 cases selected,
the number of days to bill at the three medical centers we visited
ranged from 5 to 332 days, with almost 30 percent billed after 50 days.
Promptly invoicing insurance companies for care provided is a sound
business practice and should result in improved cash flow for VA.
Officials at each of the three medical centers cited verifying and
updating patients' third-party insurance information as a continuing
impediment to billing third-party insurance companies in a timely
manner. They told us that this occurs because, among other reasons,
some patients are reluctant to provide insurance information for fear
that their insurance premiums will increase. Patients delay providing
insurance information until well after commencement of treatment and do
not always provide current information. Thus, additional time is
required to research and verify the patients' insurance coverage.
Medical center officials also told us that incomplete or inaccurate
documentation from health care providers continues to cause delays in
billing third parties. If the coders do not have sufficient data from
the provider to support a bill, the coding process can be delayed, thus
hampering timely billing of third-party insurance companies. Further,
without complete data on the actual health care services provided, the
coders may also miscode the treatment, which could result in lost
revenue.
Another impediment to timely billing is that the billing process is not
fully automated and manual intervention is required. For example, in
certain cases, the medical diagnosis is transcribed onto a worksheet to
be used for coding rather than being electronically transmitted.
Additionally, before the coders can begin the coding process, they must
first electronically download the listing of potential billable
patients. Then the coders review the electronic medical records and
assign diagnostic and procedure codes before a bill is generated.
Further, due to system limitations, bills that exceed a certain dollar
amount or number of medical procedure codes must be printed and mailed
rather than transmitted electronically. For example, in Cincinnati
bills greater than $100,000 or that have six or more medical procedure
codes must be processed this way.
Another contributing factor may be the workload levels at the medical
centers. During the second quarter of fiscal year 2004, Cincinnati
submitted 45,883 bills and had a staff of 13 coders. Concurrently,
Tampa submitted 192,407 bills and had 16 coders and Washington, D.C.
issued 64,474 bills and had 8 coders. VHA data indicated that
Cincinnati's average billing time was under 50 days for the quarter and
had the lowest bill to coder ratio. Conversely, Tampa and Washington,
D.C. exceeded the 50-day performance goal and had a much higher bill to
coder ratio. Assuming 60 workdays per quarter, we calculated the ratio
of bills issued per day to the number of coders and found:
* Cincinnati with 765 bills per day, 13 coders, and a ratio of 59 bills
to 1 coder,
* Washington, D.C., with 1,075 bills per day, 8 coders, and a ratio of
134 bills to 1 coder, and:
* Tampa, with 3,207 bills per day, 16 coders, and a ratio of 200 bills
to 1 coder.
We recognize that other factors such as the number of billable
encounters per bill and coder productivity may affect the billing
workload. However, given the wide diversity of the bill to coder
ratios, staffing may also be a contributing factor affecting days to
code and issue bills.
VA's Controls over Collections Need Strengthening:
Weaknesses in collection activities hamper VA's ability to collect all
monies due to the agency from third-party insurance companies for
veterans' care. We found that the three medical centers we visited did
not always pursue collections of accounts receivable in a timely manner
or follow up on certain partially paid insurance claims. These two
factors could negatively affect third-party collections.
Accounts Receivable Not Pursued in a Timely Manner:
VA's Handbook sets forth the requirements for collection of third-party
accounts receivables.[Footnote 7] Also, in 2003, the VHA's Chief
Business Office issued the Accounts Receivable Third-Party Guidebook
that lays out more detailed procedures.[Footnote 8] Both documents
require that once a claim has been sent to the insurance company, staff
should follow up on unpaid reimbursable insurance cases as follows:
* The first telephone follow-up is to be initiated within 30 days after
the initial bill is generated. All telephone follow-ups are to be
documented to include, at a minimum, the name, position, title and
telephone number of the person contacted, the date of contact,
appropriate second follow-up date if payment is not received, and a
brief summary of the conversation.
* A second telephone follow-up on unresolved outstanding receivables is
to be made on an appropriate (but unspecified) date and documented.
* A third follow-up call is to be made within 14 days of the second
contact and documented with a summary of the conversation and an
appropriate, but not specified, follow-up date.
* If no payment has been received by the next follow-up date, the case
may be referred by the Medical Care Collection Fund (MCCF) Coordinator
to regional counsel for further action.
We tested compliance with these policies for the same 30 cases selected
for our billing tests at each of the three medical centers we visited.
Regarding the first follow-up procedure, initial calls were made within
30 days for only 14, or about 22 percent, of the 64 cases for which
billings had not been collected within 30 days.
Second follow-up phone calls were not made in a timely manner either.
We considered 15 days after the initial follow-up of 30 days to be an
appropriate time frame since the third follow-up is to be made within
14 days after the second follow-up and cases are to be referred to
collection agencies after 60 days. Delays in making second follow-up
calls increase the risk that payments will not be collected. Within our
selected cases, four second follow-up calls were either made more than
15 days after the first call or not at all. These bills had not been
paid within 120 days after the bill was sent to the insurance company.
Both the first and second follow-up calls require that staff document
the contact's name, title, telephone number, and expected follow-up
date in the official records. However, we found that staff did not
consistently do so. For example, for the 14 cases where a follow-up
call was made during the first 30 days after the initial billing, only
seven specified a follow-up date. Entering a follow-up date would serve
as a reminder to make the second follow-up call. Further, we found that
an unclear collection policy may have contributed to VA's untimely
second follow-up efforts. Specifically, VA's Handbook requires that
second follow-up telephone calls on unresolved outstanding receivables
be made on an "appropriate date," but that date is not specified (i.e.,
the number of days elapsed since the first contact). Specifying a
follow-up date (i.e., 15 days after the first follow-up) or providing
criteria for selecting an appropriate follow-up date would clarify this
requirement and provide a benchmark on which compliance could be
measured.
Medical center officials at the three sites we visited told us that
staff shortages and a heavy workload contributed to noncompliance with
follow-up procedures. For example, Tampa officials told us that the
accounts receivable staff typically have over 1,000 cases needing
follow-up at any one time. The Cincinnati MCCF supervisor told us that
if two additional staff were available, they would be dedicated to
following up on delinquent payments.
Not Following Up on Partially Paid Claims Reduces the Possibility of
Collecting Additional Revenue:
During our review of the 90 selected cases, we noted wide variances
between the amounts billed and amounts received for patients who were
eligible for Medicare benefits. For example, in one of our selected
cases, VA billed the secondary insurance company for $60,994 but
received only $5,205, or about 9 percent.
In non-Medicare cases, when the patient has primary and secondary
insurance, VHA bills the primary insurance company and, depending on
the amount collected, bills the secondary insurance company for the
residual amount. Conversely, for Medicare patients who have secondary
insurance (i.e., Medigap or Medicare Supplemental insurance), VA is
entitled to receive payment only from the secondary insurance company
because Medicare is generally not required to and thus does not pay VA.
However, VA has not been able to determine the residual amount that the
secondary insurance company is responsible for paying because it lacks
processes and procedures for calculating the amount that would be paid
based on post-Medicare payment information (i.e., deductible and co-
insurance amounts). In such cases, VA bills the secondary insurance
company for the full amount associated with the care provided--the
amount that would be reimbursable by Medicare as well as the amount not
covered by Medicare.
The secondary insurance companies have been using a variety of
methodologies for reimbursing VA and some do not pay because they are
unable to determine the proper amount of reimbursement. As a result, in
certain cases, VA receives very little, if any, reimbursement from the
secondary insurance companies for such billings.
The Handbook describes procedures for following up on partial payments
from insurance companies. It states that payment by a third-party
insurance company of an amount which is claimed to be the full amount
payable under the terms of the applicable insurance policy or other
agreement will normally be accepted as payment in full. The unpaid
balance is to be written down to zero. However, if there is a
considerable difference between the amount collected and the amount
billed, the Handbook directs staff to take various actions to pursue
potential additional revenue. At each of the three medical centers, we
found that accounts receivable staff typically accepted partial
payments from secondary insurance companies as payment in full and
wrote down the unpaid balance to zero. Because the medical centers do
not have the post-Medicare information needed to pursue collection of
the unpaid amounts, VA may not be collecting millions of dollars
because partial payments are accepted as payment in full.
VA reported that as of September 2003, the median age of all living
veterans was 58 years, with the number of veterans 85 years of age and
older totaling nearly 764,000. As these veterans age, the demand for
care will increase, as will the number of veterans eligible for
Medicare. To be able to offset the cost of care through third-party
collections, it will be imperative in the coming years for VA to
collect the maximum amount possible from secondary insurance companies.
VA Initiatives Are Under Way to Address Operational Problems:
VA's current Revenue Action Plan includes 16 actions designed to
increase collections by improving and standardizing the collections
processes. Several of these actions are aimed at reducing billing times
and backlogs, many of which have already been implemented.
Specifically, medical centers are updating and verifying patients'
insurance information and improving health care provider documentation.
In addition, hiring contractors to code and bill old cases is reducing
backlogs. Further, the introduction of performance measures into
managers' performance contracts has provided an incentive for increased
billings and collections. In addition to those actions already taken,
VA has other initiatives under way such as automating the billing
process by implementing the Patient Financial Services System and
determining the amounts billable to Medicare secondary insurance
companies through the use of an electronic Medicare Remittance Advice.
To assist in updating and verifying patients' insurance information,
each site now has staff dedicated to (1) verify that insurance reported
by the veteran is current, (2) determine insurance coverage if the
patient does not declare any, (3) acquire pre-certifications of patient
admissions, and (4) obtain authorization of procedures from the
patient's insurance company. Additionally, medical centers have taken
actions to update demographic information on file, including insurance.
These efforts help to reduce insurance denials, produce more accurate
bills, and ensure that VA receives reimbursement for services provided.
To assist in improving medical documentation, which we reported as a
continuing operational issue, VA mandated physician use of the
Computerized Patient Record System in December 2001 and reinforced its
use through a VHA Directive in May 2003. The coders use the electronic
medical records to determine what treatment each patient received and
to document the diagnostic codes. In addition, the medical centers have
been educating the physicians about the importance of completing the
records.
To reduce billing backlogs, VHA entered into an agreement with four
vendors to code and assist with backlogs. The Washington, D.C. medical
center hired a contractor to handle a backlog of 15,000
encounters.[Footnote 9] The contractor has certified staff for coding
and billing and must meet 12 performance measures. The revenue officer
told us that the backlog was eliminated in May 2004. In addition, in
December 2003, VHA was given authority by the Office of Personnel
Management to directly hire credentialed coders at industry-compatible
salaries.
In fiscal year 2003, VHA's Chief Business Office implemented industry-
based performance metrics and reporting capabilities to identify and
compare overall VA revenue program performance. Metrics were introduced
to measure collections, days to bill, gross days revenue outstanding,
and accounts receivable over 90 days. For both network and medical
center directors, the metrics and associated performance targets were
incorporated into annual performance contracts effective fiscal year
2003. VHA officials attribute much of the decrease in days to bill and
increased billings and collections to these performance measures. For
example, VA reported that nationally the average days to bill insurance
companies for the first half of fiscal year 2004 was about 74 days,
which is an improvement from their fiscal year 2000 average days to
bill of 117 days. However, VHA's average days to bill for that period
exceeded the performance goals of 50 days and 47 days for the first and
second quarters of fiscal year 2004, respectively. The industry
standard is 10 days.[Footnote 10]
In addition to actions already taken, VA's Plan has several other
initiatives under way for improving billing times and increasing
collections. For example, the Patient Financial Services System is
designed to integrate the health care billing and accounts receivable
software systems to replace VA's current legacy system. The system is
intended to increase staff efficiency through a streamlined,
standardized, re-engineered process; create more accurate bills; and
shorten bill lag times through automation. VA officials believe that
this initiative, when implemented, will reduce manual intervention
noted earlier in our report as a reason for delayed billings. However,
implementation is behind schedule.
Another effort under way, the electronic Medicare Remittance Advice
project, helps to address obtaining allowable payments from secondary
insurance companies, rather than accepting partial payments that are
significantly lower than billed amounts as full payment. This project
involves the electronic submission of claims to a fiscal
intermediary[Footnote 11] to receive remittance advice on how Medicare
would have paid the claim if it were legally bound to pay VA for care.
The remittance advice, which will be attached to VA health care claims,
will enable secondary insurance companies to determine the correct
amount to reimburse VA. Further, VA believes it will be able to more
accurately reflect the amount of its outstanding receivables and be in
a strengthened position to follow up on partial payments, which it
deems incorrect. The completion date for this project was November 2003
but has been delayed due to software issues. VA officials told us they
plan to roll out the new system beginning in August 2004.
Although the Plan provides another step forward in potentially
improving operations and increasing collections, it is still in
progress and many of the actions are not scheduled for implementation
until at least fiscal year 2005. Therefore, it is too early to
determine whether the Plan will successfully address operational
problems and increase collections when fully implemented.
In closing, Mr. Chairman, we believe strengthening internal controls
such as clarifying billing and claims follow-up procedures and
consistently implementing policies and procedures could help reduce
billing times and increase collections. Even assuming that VA's Revenue
Action Plan works as contemplated, these additional controls are needed
to maximize VA revenues to the fullest extent for enhancing its medical
care budget.
Our report, which is being released at this hearing, makes five
recommendations to strengthen internal controls that will facilitate
more timely billings and improve collection operations.
This concludes my statement. I would be happy to answer any questions
you or other members of the subcommittee may have.
Contacts and Acknowledgments:
For information about this statement, please contact McCoy Williams,
Director, Financial Management and Assurance, at (202) 512-6906, or
Alana Stanfield, Assistant Director, at (202) 512-3197. You may also
reach them by e-mail at [Hyperlink, williamsm1@gao.gov] or
[Hyperlink, stanfielda@gao.gov]. Individuals who made key contributions
to this testimony include Lisa Crye, Jeff Isaacs, and Sharon Loftin.
[End of Section]
FOOTNOTES
[1] U.S. General Accounting Office, VA Health Care: VA Has Not
Sufficiently Explored Alternatives for Optimizing Third-Party
Collections, GAO-01-1157T (Washington, D.C.: Sept. 20, 2001).
[2] VA Office of Inspector General, Audit of the Medical Care
Collection Fund Program, Report No. 01-00046-65 (Washington, D.C.: Feb.
26, 2002).
[3] U.S. General Accounting Office, VA Health Care: VA Increases Third-
Party Collections as It Addresses Problems in Its Collections
Operations, GAO-03-740T (Washington, D.C.: May 7, 2003).
[4] U.S. General Accounting Office, VA Medical Centers: Further
Operational Improvements Could Enhance Third-Party Collections, GAO-
04-739 (Washington, D.C.: July 19, 2004).
[5] U.S. General Accounting Office, Standards for Internal Control in
the Federal Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: November
1999).
[6] Billing performance goals (e.g. 50 days from the date of patient
discharge) are computed as averages for designated time frames. Days to
bill are calculated from the billing date back to the date when the
patient was discharged.
[7] VA Handbook 4800.14, Medical Care Debts, Department of Veterans
Affairs, (Washington, D.C.: Dec. 8, 2003).
[8] Accounts Receivable Third-Party Guidebook, Department of Veterans
Affairs, 2003.
[9] An encounter is defined as a single medical treatment.
[10] As we noted in our 2003 report, VA's performance does not compare
favorably to some industry benchmarks, such as the number of days
required to bill. However comparisons between VA and the private sector
should take into account how VA's processes differ from those in the
private sector. For instance, VA has the additional step of determining
whether the care is service-connected, and VA bills for both facility
and physician charges. By comparison, private sector hospitals may only
bill for facility charges.
[11] A private company that contracts with Medicare to pay Medicare
Part A and some Part B bills.
