§1703D — Title 38 Veterans' Benefits | U.S. Code

Summary

The Secretary must pay bills for hospital care, medical services, or extended care that non-VA providers give under this law quickly. If the bill is sent electronically and has all required information, it must be paid within 30 calendar days. If it is a paper bill with all required information, it must be paid within 45 calendar days. If a bill is denied, the Secretary must tell the provider why within the same 30- or 45-day deadlines and say what extra information is needed. Once the extra information is sent, the Secretary must decide to pay, deny, or otherwise resolve the bill within 30 days. Providers must send their bill within 180 days after they gave the care. Overdue payments may earn interest at the Treasury rate set under section 3902 of title 31, and the Secretary must report at least once a year on late payments by paper and electronic bills. The Secretary can recover overpayments but must notify providers and let them dispute the debt before taking money, unless waiting would risk losing the full recovery. The Secretary can bar providers for fraudulent bills, must give providers a list of what makes a clean claim and consult industry groups, must give 30 days’ notice of changes, and may use contractors to process claims and study outside processing. Defined terms: appropriate committees of Congress — the Senate and House Veterans’ Affairs and Appropriations committees; clean electronic claim — an electronic bill that has nearly all needed data; clean paper claim — a paper bill that has nearly all needed data; fraudulent claims — knowing false statements to get payment; health care entity or provider — non-VA providers who give care under this law.

Title 38, §1703D

Veterans' Benefits — Source: USLM XML via OLRC

(a)(1)Notwithstanding any other provision of this title or of any other provision of law, the Secretary shall pay for hospital care, medical services, or extended care services furnished by health care entities or providers under this chapter within 45 calendar days upon receipt of a clean paper claim or 30 calendar days upon receipt of a clean electronic claim.

(2)If a claim is denied, the Secretary shall, within 45 calendar days of denial for a paper claim and 30 calendar days of denial for an electronic claim, notify the health care entity or provider of the reason for denying the claim and what, if any, additional information is required to process the claim.

(3)Upon the receipt of the additional information, the Secretary shall ensure that the claim is paid, denied, or otherwise adjudicated within 30 calendar days from the receipt of the requested information.

(4)This section shall only apply to payments made on an invoice basis and shall not apply to capitation or other forms of periodic payment to entities or providers.

(b)A health care entity or provider that furnishes hospital care, a medical service, or an extended care service under this chapter shall submit to the Secretary a claim for payment for furnishing the hospital care, medical service, or extended care service not later than 180 days after the date on which the entity or provider furnished the hospital care, medical service, or extended care service.

(c)(1)Sections 3729 through 3733 of title 31 shall apply to fraudulent claims for payment submitted to the Secretary by a health care entity or provider under this chapter.

(2)Pursuant to regulations prescribed by the Secretary, the Secretary shall bar a health care entity or provider from furnishing hospital care, medical services, and extended care services under this chapter when the Secretary determines the entity or provider has submitted to the Secretary fraudulent health care claims for payment by the Secretary.

(d)(1)Any claim that has not been denied with notice, made pending with notice, or paid to the health care entity or provider by the Secretary shall be overdue if the notice or payment is not received by the entity provider within the time periods specified in subsection (a).

(2)(A)If a claim is overdue under this subsection, the Secretary may, under the requirements established by subsection (a) and consistent with the provisions of chapter 39 of title 31 (commonly referred to as the “Prompt Payment Act”), require that interest be paid on clean claims.

(B)Interest paid under subparagraph (A) shall be computed at the rate of interest established by the Secretary of the Treasury under section 3902 of title 31 and published in the Federal Register.

(3)Not less frequently than annually, the Secretary shall submit to Congress a report on payment of overdue claims under this subsection, disaggregated by paper and electronic claims, that includes the following:

(A)The amount paid in overdue claims described in this subsection, disaggregated by the amount of the overdue claim and the amount of interest paid on such overdue claim.

(B)The number of such overdue claims and the average number of days late each claim was paid, disaggregated by facility of the Department and Veterans Integrated Service Network region.

(e)(1)The Secretary may deduct the amount of any overpayment from payments due a health care entity or provider under this chapter and may use any other means authorized by another provision of law to correct or recover overpayments.

(2)Deductions may not be made under this subsection unless the Secretary has made reasonable efforts to notify a health care entity or provider of the right to dispute the existence or amount of such indebtedness and the right to request a compromise of such indebtedness.

(3)The Secretary shall make a determination with respect to any such dispute or request prior to deducting any overpayment unless the time required to make such a determination before making any deductions would jeopardize the Secretary’s ability to recover the full amount of such indebtedness.

(f)(1)The Secretary shall provide to all health care entities and providers participating in a program to furnish hospital care, medical services, or extended care services under this chapter a list of information and documentation that is required to establish a clean claim under this section.

(2)The Secretary shall consult with entities in the health care industry, in the public and private sector, to determine the information and documentation to include in the list under paragraph (1).

(3)If the Secretary modifies the information and documentation included in the list under paragraph (1), the Secretary shall notify all health care entities and providers described in paragraph (1) not later than 30 days before such modifications take effect.

(g)(1)In processing a claim for compensation for hospital care, medical services, or extended care services furnished by a non-Department health care entity or provider under this chapter, the Secretary may act through—

(A)a non-Department entity that is under contract or agreement for the program established under section 1703(a) of this title; or

(B)a non-Department entity that specializes in such processing for other Federal agency health care systems.

(2)The Secretary shall seek to contract with a third party to conduct a review of claims described in paragraph (3) that includes—

(A)a feasibility assessment to determine the capacity of the Department to process such claims in a timely manner; and

(B)a cost benefit analysis comparing the capacity of the Department to a third party entity capable of processing such claims.

(3)The review required under paragraph (2) shall apply to claims for hospital care, medical services, or extended care services furnished under section 1703 of this title that are processed by the Department.

(h)(1)Not later than 90 days after the date of the enactment of the Caring for Our Veterans Act of 2018, the Secretary shall submit to the appropriate committees of Congress a report on the feasibility and advisability of adopting a funding mechanism similar to what is utilized by other Federal agencies to allow a contracted entity to act as a fiscal intermediary for the Federal Government to distribute, or pass through, Federal Government funds for certain non-underwritten hospital care, medical services, or extended care services.

(2)The Secretary may coordinate with the Department of Defense, the Department of Health and Human Services, and the Department of the Treasury in developing the report required by paragraph (1).

(i)In this section:

(1)The term “appropriate committees of Congress” means—

(A)the Committee on Veterans’ Affairs and the Committee on Appropriations of the Senate; and

(B)the Committee on Veterans’ Affairs and the Committee on Appropriations of the House of Representatives.

(2)The term “clean electronic claim” means the transmission of data for purposes of payment of covered health care expenses that is submitted to the Secretary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional information from the entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services.

(3)The term “clean paper claim” means a paper claim for payment of covered health care expenses that is submitted to the Secretary which contains substantially all of the required data elements necessary for accurate adjudication, without obtaining additional information from the entity or provider that furnished the care or service, submitted in such format as prescribed by the Secretary in regulations for the purpose of paying claims for care or services.

(4)The term “fraudulent claims” means the knowing misrepresentation of a material fact or facts by a health care entity or provider made to induce the Secretary to pay a claim that was not legally payable to that provider.

(5)The term “health care entity or provider” includes any non-Department health care entity or provider, but does not include any Federal health care entity or provider.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The date of the enactment of the Caring for Our Veterans Act of 2018, referred to in subsec. (h), is the date of enactment of Pub. L. 115–182, which was approved June 6, 2018.

Amendments

2018—Subsec. (e)(1). Pub. L. 115–251, § 204, substituted “may deduct” for “shall deduct” and inserted before period at end “and may use any other means authorized by another provision of law to correct or recover overpayments”. Subsec. (g)(3). Pub. L. 115–251, § 211(a)(5), substituted “of this title” for “of this Act, as amended by the Caring for Our Veterans Act of 2018,”.

Statutory Notes and Related Subsidiaries

Processing of Claims for Reimbursement Through Electronic Interface Pub. L. 115–182, title I, § 114, June 6, 2018, 132 Stat. 1423, provided that: “The Secretary of Veterans Affairs may enter into an agreement with a third-party entity to process, through the use of an electronic interface, claims for reimbursement for health care provided under the laws administered by the Secretary.”

§1703D Prompt Payment Standard