Falling through the Health Net

"Every morning when I wake up now I'm paralyzed almost. I have tingling and pain from the waist up." That's Don Ainsworth, describing the start to his day. It can take him up to 30 minutes to get out of bed in the morning.

Ainsworth is a Vietnam Veteran who faces multiple health challenges and lives far-removed from a Veterans Administration (VA) facility. He is exactly the sort of patient Congress had in mind when it funded the Veteran's Choice Program. But the program has been beset by problems for much of its roll-out, frustrating both veterans and the private sector doctors trying to help them.

Choice Basics

The $10 billion three-year Choice program was launched in August of 2014 after reports revealed that many VA facilities were overloaded with appointments and veterans were waiting months to get medical attention. Its goals were to decrease wait times at an over-extended VA and give veterans a greater degree of flexibility in deciding where to seek care.

Qualifying veterans can get treated by a non-VA physician, and the Choice program is supposed to pay for those services through a third-party administrator. In Wyoming, that third-party administrator is a company called Health Net (which was acquired by St. Louis-based Centene Corporation earlier this year).

To qualify for Choice, a veteran must live more than 40 miles away from the closest VA facility or face more than a 30-day waiting period before a VA doctor can see him or her.

Ainsworth qualifies on both counts. "I was one of the first people involved with it here. And that was going to be the answer to the VA problem," he said of Choice.

Since enrolling in the Choice program in the fall of 2014, however, Ainsworth has repeatedly struggled to make the system work for him. He says Health Net has mishandled his medical documents, kept him in the dark about program requirements, failed to follow up on his difficulties and been slow in paying physicians who have treated him.

Contacted for comment, Health Net Communications Director Molly Tuttle wrote in an email that the company had scheduled over 885 appointments for Wyoming veterans this November, up from 800 last year. Tuttle said it was company policy to provide written responses to media inquiries rather than to engage in direct question and answer sessions with reporters.

Holding Pattern

Poor communication from the corporation was a recurring theme in interviews with Ainsworth, VA employees, and outside healthcare providers.

Barbara Minar is one of 28 "Choice coordinators" employed by the VA facility in Cheyenne. Her job is to help veterans navigate the Health Net system, and she said that while complaints about Health Net have decreased since she started working as a coordinator a year ago, they are still commonplace.

Health Net is supposed to coordinate care for veterans by, among other things, setting up appointments and paying doctors. Minar said that sometimes Health Net would schedule appointments with the wrong type of specialist. Other times, Health Net would tell a veteran that he or she would be getting a follow-up call to schedule care, but that follow up call would never come.

These snafus are compounded by the long wait times veterans and Choice coordinators like Minar face when trying to talk to somebody at Health Net. When asked for advice in reaching someone at the company, Sam House, a public affairs officer for the Cheyenne VA, joked, "grab your lunch and a neck pillow."

A test call to Health Net's service line took 81 minutes to go through, and Ainsworth, Minar and House agreed that sort of wait was far from unusual. A large percentage of Minar's working day is spent on hold with the company, and Ainsworth complained that even after he breaks through to someone at the California call center, "you never know who you're going to get."

Late Payments,

Lost Paperwork

As difficult as navigating Health Net's system can be for patients, health care providers sometimes find the company even more plodding and opaque. "What we've seen in (the Cheyenne VA's) area is that a number of providers have not been paid," House said.

Overall, House called late payment for services rendered "one of the biggest problems (Health Net) has had," and said that due to long delays in payment, "a number of providers have not participated (in Choice)." Minar added that "(the VA) is very concerned any time we lose any of our providers in the State of Wyoming," but confirmed that doctors have dropped out.

The delays in payment can stem from multiple reasons. Some providers send incomplete information to Health Net, Minar said, or they send information to the wrong place.

Once in Health Net's possession, "those bills need to get sent to Virginia where they're audited," Minar continued. This introduces another point in the process where a misfiling or clerical error can add weeks or months to how long a provider has to wait to get paid.

Small Providers,

Big Debt Load

These gaps in payments, some lasting a year or more, can present big obstacles to small providers like Kendra Simms, a Saratoga chiropractor. Simms has long treated veterans and had no trouble getting her bills paid by the VA in Cheyenne when that facility directed someone to her as an outside contractor.

Instead, "it was this transition to the VA Choice Program when we stopped getting paid," Simms said. In a mid-November interview, Simms said it had been "over a year now that we have not seen payment (from Health Net)." After months had gone by without compensation, Simms said that over the summer she was forced to drop the half-dozen VA Choice patients she had been treating. Simms described it as a tortured decision: "(Veterans) are the ones that need the care, and they're not getting the care they need because of this problem."

In addition to the late payments, Simms said she took issue with "excessive documentation" required by Health Net, calling it "above and beyond what we do for typical patients." Continuing, the chiropractor noted dryly, "When you're doing extra work and not getting paid for it, it becomes an issue."

Simms said the waiting and delays weren't simply headaches for small practitioners with limited cash flow, either. "Let's say a patient is in emergent need of services and we have to submit for approval (of treatment) and it takes two weeks–well, we've missed two weeks that they could have been getting treated," she said. Asked if she thought her patients had suffered negative health consequences because of these delays, Simms said, simply, "I do."

There's no alternative: Minar, the Choice coordinator for the Cheyenne VA, said, "If (a treatment plan) wasn't authorized, then it won't get paid for." A veteran in pain would just have to wait while Health Net approved the treatments ordered by his or her doctor.

In the red,

Wyoming-wide

Health Net's pattern of delinquency and delay is hardly limited to Carbon County or smaller clinics. The San Diego Union-Tribune, National Public Radio and other outlets have reported late payments to providers and slow-moving bureaucratic machinery delaying care for veterans in Colorado, California and other states serviced by Health Net. In early November, an employee at the Mountain View Regional Hospital in Casper confirmed that doctors at the hospital were "doing some follow-up appointments (with Choice patients), but they're not taking any new (Choice) patients." She cited non-payment as the reason the hospital was pulling back from the program at that time.

"(Different providers) all tell you the same thing," Ainsworth recalled. 'I'm so sorry sir, thank you for your service but we can't do anything for you because we haven't been paid in over a year.'"

At the end of November, Mountain View Regional Hospital's Chief Financial Officer Renee Schroyer said the hospital was accepting Choice patients.

Schroyer did describe Health Net as being "very, very erratic," in paying its bills, however. When asked how late Health Net had been in getting payments to the hospital, all Schroyer would say was "Months. Many, many months."

Turning a Corner

Pressure from the VA, veterans' groups and politicians like Wyoming's U.S. Senator John Barrasso may be effecting some positive change in Health Net's management of the Choice Program.

Tuttle, of Health Net, wrote "Health Net Federal Services has been working with the Department of Veterans Affairs on ways to overcome provider reimbursement delays and improve the process going forward. Recently, we collaborated with VA on a contract modification that expedites the process and alleviates much of the current, unforeseen backlog of claims in the system, allowing us to pay providers for their services more timely (sic)." Tuttle did not explain what contract modification entailed.

Schroyer said that after she reached out to Barrasso's office, some of the money owed her facility started coming in from Health Net. "We're getting pretty current (on what we're owed), but there's still some outstanding (debt)," she said. Schroyer was unsure what, if anything, Barrasso had done to get the cash flowing, but expressed hopefulness that Health Net's full debt-burden to the hospital would be resolved by the end of the year. Barrasso's Press Secretary, Laura Mengelkamp declined to provide any specifics, but did write, "If a veteran contacts our office, they will receive immediate attention for any problems they've run into."

"We just don't know (what comes next)," House, the public affairs officer at the Cheyenne VA said about the Choice program. The three-year program is set to expire in August of 2017, and no one is yet sure how the program will change or if it will continue. "In 2017 we do know something will happen," House said.

Ainsworth

Ainsworth too, has seen some promising developments in his predicament. At the end of November, a badly-needed operation on his neck was finally authorized and scheduled by Health Net. Ainsworth had spent over a year (and countless hours on hold) wrangling with Health Net while seeking approval for the surgical treatment.

Whatever fate awaits the Choice Program nationally, it has already left a dubious legacy in Ainsworth's eyes. "I worked for Hack (of Hack's Tackle) for 12 summers, and I don't know if I'm ever going to be able to drive a shuttle again. And you know why?" Ainsworth paused for a beat then answered his own question: "Because they waited so long."