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Reimbursement in healthcare is sophisticated — and navy insurance coverage provides one other layer. A typical false impression is that the Division of Veterans Affairs (VA) instantly processes and pays all claims. In actuality, the VA oversees the method, however different entities more and more deal with administrative duties. This misunderstanding results in billing errors, denials, and delays that affect veterans and their households.
This challenge isn’t new, but it surely’s worsening. As VA staffing cuts and attrition enhance, extra veterans are searching for care locally. Well being programs that don’t perceive how navy payers function danger being rapidly overwhelmed. Having navigated this method each personally and professionally, I’ve seen firsthand how confusion can delay care and jeopardize entry.
Navy payers aren’t interchangeable
Too usually, suppliers deal with all navy claims the identical means — sending them to the VA and hoping for the perfect. However there are a number of payer sorts, they usually operate very in a different way.
The MISSION Act of 2018 reshaped the panorama by increasing eligibility and establishing the Group Care Community (CCN), which permits veterans to obtain care exterior of VA amenities. Whereas this broadened entry, it additionally launched new payer complexity. CCN is managed by third-party directors, reminiscent of Optum and TriWest, somewhat than the VA. If a supplier mistakenly submits a CCN declare on to the VA, it is going to be denied as a result of the VA doesn’t have a report of the care episode.
Some claims are nonetheless processed by way of VA Payment Foundation, a legacy system utilized in restricted instances. Complicated Payment Foundation with CCN is a typical error that causes denials and delays.
The Millennium Invoice (Mill Invoice) covers emergency care when veterans are unable to succeed in a VA facility. These are extremely time-sensitive: amenities should notify the VA inside 72 hours and file the declare inside 90 days. Lacking these deadlines results in automated denials, even when the care was legitimate and obligatory.
One other misunderstood payer is CHAMPVA, which covers spouses and dependents of veterans with service-connected disabilities — not the veterans themselves. It’s fully separate from TRICARE, which has 5 distinct plans protecting active-duty members, reservists, and retirees, every with its personal eligibility and reimbursement guidelines.
Treating all these packages as interchangeable isn’t only a clerical mistake — it disrupts billing, reimbursement, and finally, veterans’ care.
Why it’s getting more durable — and why it issues now
This confusion has lengthy existed, however strain on the system is rising. Latest plans to chop over 80,000 VA jobs, primarily in billing and administrative roles, have been scaled again however not deserted. The division now goals to remove 30,000 positions by fiscal 2025, largely by way of attrition. With fewer employees, extra care will shift to group suppliers by way of CCN — however with much less administrative assist to handle it.
The shift is already underway. Between 2018 and 2021, the variety of veterans handled by group major care suppliers rose 107%. A 2024 report confirmed a 15–20% progress in referrals to group care, and that quantity is more likely to proceed climbing.
Laws continues to increase eligibility. The COMPACT Act of 2020 elevated entry to community-based emergency psychological well being care to forestall veteran suicide. The PACT Act of 2022 expanded once more in 2024, extending eligibility for veterans uncovered to poisonous substances. These have been important steps ahead, however additionally they spiked declare volumes and complexity.
Fewer VA employees, extra veterans, and increasing eligibility imply longer wait occasions, extra denials, and higher administrative pressure. Veterans should nonetheless acquire referrals and authorizations by way of the VA — a course of that may take up to twenty-eight days and could also be interrupted at any level.
Widespread pitfalls embrace:
- Authorization & eligibility – Lacking authorizations, mismatched locations of service, or unlisted procedures within the SAR/RFS.
- Billing & submission – Late submitting (past 180 days), unsupported codes, lacking modifiers, or duplicate claims.
- Supplier coordination – Mismatched NPI/TIN info or incorrect payer sequencing that delays reimbursement.
All of that is occurring as declare volumes climb and VA staffing thins. With out course of enhancements and stronger partnerships, delays and denials will multiply — with veterans paying the worth.
What suppliers should do: put together and companion
The most important mistake suppliers make is assuming the VA operates like a industrial payer. It doesn’t. Submitting a Mill Invoice emergency declare to CCN, or a CCN declare on to the VA, ensures denial. Understanding payer kind is important.
Suppliers ought to ask:
- Are our billing groups educated to differentiate between navy payers?
- Do we all know which payers require the veteran to provoke authorization?
- Are we prepared for a possible 15–20% enhance in veteran quantity over the subsequent 12 months?
Many amenities deal with their navy claims effectively — for now. However as quantity will increase and VA capability decreases, workloads will rapidly surpass staffing.
On the different finish of each breakdown is a veteran who could not know the distinction between the VA, CCN, or TRICARE. Many veterans are unaware that they’re eligible for CCN. Serving to them navigate the system with accuracy and empathy is a part of the supplier’s obligation of care.
That’s the place preparation and partnerships play an important function. Collaborating with organizations focusing on navy claims may help suppliers streamline operations, scale back denials, and guarantee well timed reimbursement.
Specialised companions may help suppliers:
- Determine payer kind precisely to keep away from misrouted claims.
- Use automation to flag lacking documentation or errors earlier than submission.
- Observe authorizations so veterans don’t fall by way of the cracks.
- Monitor reimbursement tendencies to anticipate delays and reply rapidly.
- Lighten administrative load, releasing employees to deal with affected person care.
Outdoors experience doesn’t substitute inner groups — it reinforces them. It builds resilience at a time when veteran volumes and declare complexities are each rising.
Serving those that served
Behind each declare is an individual — a widow, a partner, a baby, or a veteran dealing with trauma or loss. Understanding these programs isn’t simply an administrative requirement; it’s a service.
When claims are denied as a result of they have been despatched to the incorrect payer, somebody should rectify the error — usually, it’s the veteran or a grieving member of the family. It’s a preventable burden that compounds stress at already troublesome occasions.
As declare volumes rise and VA programs evolve, suppliers can defend each their operations and sufferers by partnering with specialists who completely perceive navy reimbursement. The proper companion not solely accelerates cost and reduces denials — it ensures that those that serve our nation obtain the care and respect they deserve.
Picture: mstahlphoto, Getty Photographs
Zachary Schultz, CSMC, CRCR, is a nationally acknowledged skilled in out-of-state Medicaid and employees’ compensation coverage and declare reimbursement. As Senior Director of Product Coverage and Options at EnableComp, he maintains relationships with state regulatory companies, giant PPO networks, and payers. He additionally screens and analyzes authorized developments and legislative modifications that affect EnableComp’s enterprise and healthcare companions. Earlier than becoming a member of EnableComp, he spent 10 years in operational administration roles and served within the US Military, with deployments to Afghanistan for Operation Enduring Freedom.
This publish seems by way of the MedCity Influencers program. Anybody can publish their perspective on enterprise and innovation in healthcare on MedCity Information by way of MedCity Influencers. Click on right here to learn the way.
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