Veterans, doctors alike stranded as Vet Choice fails to pay its bills
By STEPHANIE EARLS | The Gazette (Colorado Springs, Colo.) (Tribune News Service) | Published: March 12, 2018
One day in 2016, Army veteran Jason White finished cleaning his pistol, wrapped his hand around the grip, and put the barrel to his temple.
He'd had enough. Five years after his deployment in Afghanistan ended when an IED explosion pinned him between two vehicles, he was 100 percent disabled, in pain and still at war inside. This time, though, it felt like he was fighting the enemy alone.
"I'd had three deaths in the family, and four guys in my unit who'd committed suicide," he said. "Everything was going wrong, everything was bad."
White pulled the trigger, but the weapon jammed.
After his wife learned what he had done she accompanied him to the Department of Veterans Affairs' Floyd K. Lindstrom Clinic in Colorado Springs, where White said he was told he faced a six-month wait to see a therapist.
"They knew I was suicidal and still it was six months to talk to someone," said White, 30. "My wife was extremely mad."
A few days later, White got a call saying the VA had referred him to the Veterans Choice Program, a federally-funded initiative that would pay for his visits to a provider in the community. An appointment with participating Colorado Springs psychologist Michael Sunich was set up for the following week.
"I was skeptical of seeing someone to talk about all the issues to begin with ... things I wouldn't even talk with my wife about ... but I started seeing him weekly," said White, whose five years of active duty had left him with a crushed spine, severe traumatic brain injury, post traumatic stress disorder and insomnia, among other debilitating ailments.
After several months of meeting with Sunich, White says his life "turned around."
"Without him, I probably wouldn't be here," he said.
Gulf War veteran Frederick Zappone said he feels the same.
"I went to Desert Storm and came back and there wasn't the help for us, the people to talk to. A lot of soldiers turned to the bottle, or to drugs. My battle buddy didn't get the help he needed and he killed himself," said Zappone, 52, who sees Sunich through Veterans Choice for one-on-one and group sessions. "Somebody like doc is gold to me. There's no question he's saved my life, or saved me from taking the life of someone else."
Their "doc" debated whether to let the men know he'd been treating them for free for months, and battling Health Net Federal Services — the third-party manager of Vet Choice for the VA — at almost every step.
"This isn't their fault. They checked all the right boxes," said Sunich, who's worked with veterans since 1980 and considers the job more calling than career. "But I checked all the right boxes, too."
Sunich's Gone West Consulting and Psychological Services is a modest private practice based in a couple rooms in a complex off South Eighth Street. Overhead's low, but after months of submitting claims and receiving no payments from Health Net — nor a reissued check for $4,000 after the original never arrived — Sunich said his office bills were past due and the pressure was starting to affect his life at home, where he and his wife, Julie, are raising 14-year-old twins.
By the end of 2017, around 85 percent of Gone West's patients were veterans referred through the Choice program, and the VA owed him more than $20,000.
"People are going to be told next month that they won't be getting rent, etcetera," said Julie Sunich in January. "If we were independently wealthy and he was retired and wanted to do this for the benefit of the country ... but that's not really where we are right now. It is making an impact on our family."
Julie reminded her husband that if payments didn't start showing up soon, he was going to have to consider some hard decisions.
"We'll get paid," Michael assured his wife.
"Yeah, maybe," Julie said. "But when?"
A month later, the check for $4,000 finally arrived.
Roots of the problems
The 5th Congressional District, an area comprising Colorado Springs and its suburbs, including Fort Carson, the Air Force Academy, Peterson and Schriever Air Force bases, is home to more military veterans than any other district in America.
But unlike in other cities with large military and veteran populations, the VA does not operate a medical center in the Springs. For the district's estimated 96,000 former military, the closest VA hospital is in Denver.
The Lindstrom Clinic is new and impressive and offers a range of services, but it's an outpatient facility, not a hospital. The clinic's honeymoon, too, has been a rough one, plagued by mismanagement, complaints and scandal as the understaffed and overbooked center struggled to meet one of the driving arguments behind its construction: improving access to care — especially mental health and suicide prevention services — for veterans living along the southern Front Range.
Within two years of opening in 2014, Lindstrom patients were facing some of the nation's longest wait times — 30 days or more — and, in a number of cases, records had been falsified to make it appear drastically otherwise, according to a 2016 report by the VA's Office of Inspector General.
In their response to the report, Colorado lawmakers demanded a congressional probe. They also wanted to know why the VA wasn't taking advantage of Veterans Choice, the federal program created to address precisely this scenario.
The VA's 2016 investigation of Lindstrom found that, of 450 cases reviewed, 288 patients who qualified for the zero co-pay Vet Choice program didn't receive timely referrals. In some cases, referrals weren't made at all.
U.S. Rep. Mike Coffman questioned the justification for VA's seeming reluctance to "farm out" patients to the private sector.
"If they allow it to work, what the Choice act will do is stimulate some kind of competition where the VA will have to treat the veterans as actual patients rather than numbers," he said.
When it was signed into law in late 2014, with $10 billion in funding, the Veterans Access, Choice and Accountability Choice Act marked a major revolution in health care access for veterans facing long waits, or drives, for appointments at their local VA clinics.
But after three years, the hastily-constructed policy — and its management by Health Net Federal Services — is effectively driving away the very community caregivers on which it relies.
"Everybody who's had anything to do with Health Net has a horror story about it," said Colorado Springs psychologist Judith Ray. "A lot of my colleagues have heard those horror stories and said, 'I will not accept Veterans Choice.'"
'A pretty risky business'
Putting people back together is expensive, and a process that cannot be done piecemeal, said licensed professional counselor and Desert Storm veteran Jeffery Erickson, whose father fought in Vietnam.
In January, Erickson was still awaiting payment for Vet Choice patients he'd seen three months prior. If he has to, he'll keep seeing them pro bono, he said.
"A whole generation has gone by and we're still in combat. These people are trained to run toward conflict. They've seen and done things most people can't imagine, in service of their country, then they get back and have 40 or 50 years of a life left that they've got to relearn how to live," Erickson said. "The VA should be doing everything it can to make that easier for them."
Health Net Federal Services and another regional contractor that processes VA payments to civilian providers, TriWest Healthcare Alliance, became the target of a federal grand jury investigation after an audit by the VA's internal watchdog in late 2017 found that improper billing led to payment errors in approximately 224,000 of 2 million Choice claims processed between the program's start date in November 2014 and Sept. 30, 2016.
As providers in Colorado Springs were fighting to get paid in dribs and drabs, the audit found that Health Net and TriWest collected an estimated $39 million more than they should have, in part from payments that were reimbursed by VA but not distributed.
"The VA, the Choice program, they're the worst," said Karen Lee, owner of the Springs' Ponderosa Medical Billing, which serves 11 private sector mental health providers who, collectively, are owed about $73,000 by Vet Choice. "All insurance companies take between 14 to 30 days to process and pay a claim, some a lot sooner these days. Vet Choice, you send claims in and sometimes they'll pay in less than a month and other times, it's three to four to five to six months, or never. For a doctor to do this and expect to get paid for it ... it's a pretty risky business."
President Donald Trump repeatedly has said that overhauling the VA and improving care — specifically mental health care — for veterans is a top priority. In January, he seemed to follow through on that promise, signing an executive order granting unconditional access to psychological and suicide prevention services and resources to "new veterans" for at least a year after their discharge, retirement or separation from service, a critical period when the symptoms of PTSD can begin to take root and treatment can be most effective. That order was scheduled to take effect last Friday.
But how is a system that's clearly unequipped to manage its current obligations to veterans prepared to handle tens of thousands of new troops returning from America's longest war?
Karen Lee has noticed the trend among her mental health provider clients, and anecdotally at large: More are choosing to cut back on the number of Vet Choice patients they treat, or have made the decision not to participate in the program at all.
"The ones I'm worried about are the veterans. That's who it's affecting more, and especially when it comes to mental health," Lee said. "These veterans they're treating, a lot are suicidal. They're fragile. A doc isn't just going to say, come back in three months and we'll start treatment again when you're reauthorized and I can get paid."
Limited options for providers
Sunich didn't know much about Vet Choice program when he got the call in July 2016 asking if he would begin treating a veteran whose visits would be authorized and reimbursed at $125 a session. The program sounded like a good one: letting vets see someone in their community who can see them right away.
When the payment timeline started to drag late last summer, Sunich chalked it up to the slow trickle down of $2.1 billion in emergency funding allocated by Congress in August to extend the program.
"We would send in a request for reauthorization and, on good faith, I continued to see these guys operating on the assumption that they would be authorized, because the VA seemed to have a strong commitment to mental health and suicide prevention," Sunich said. "But we never heard back and I stopped getting paid."
Sunich and other providers like him have limited options — all bad: work with no guarantee of pay, abruptly stop treating some of their most emotionally and psychologically vulnerable patients, or pass the costs on to veterans. The 2016 review by the VA cited a number of cases where unpaid bills for Vet Choice trickled down to veterans and negatively impacted their credit ratings.
"Some of these guys struggle to afford a co-pay, so I'm not going to look to them to cover that," Sunich said. "This is the VA's responsibility."
Ponderosa Medical Billing serves about 120 local doctors and health providers; about half are in the mental health field and most are small practices — "one doctor shops," such as those run by Michael Sunich and Judith Ray, Lee said.
"Sunich is owed the most, at $28,000, but almost every single one of them (who accepts Vet Choice) is owed between $4,000 and $5,000," said Lee, who's been in the medical billing business for almost 30 years.
Some of the Vet Choice claims have been outstanding since early 2017.
The why of it seems to be not a lack of funds but a patient reauthorization process that seems engineered to result in reimbursement denials, Lee said. Following up on a claim or authorization requires devoted oversight, patience and hours upon hours on the phone.
"The initial authorization usually is pretty smooth, but when it's time to reauthorize we turn in the paperwork and it takes up to three months for them to say it's OK to start seeing the doctor again. Or, a reauthorization is canceled and they don't let anyone know," Lee said. "If you call, you're on hold half a day waiting to talk to someone and then they probably can't help you."
Compounding the frustration is the fact that, because the program is run by the government, there's no consumer watchdog to hear complaints.
"Mental health claims are one of the easiest specialties for me to file for, except when it comes to the VA, but there's no governing board, no insurance board for me or doctors to complain to, other than Congress," Lee said.
'No rhyme or reason'
Judith Ray started seeing patients through Vet Choice in late 2015.
"I was kind of dumped into it without knowing what I was getting in to, but I will not turn down a veteran," said Ray, who's treated hundreds of veterans in her career.
She saw one of her Vet Choice patients — a man whose PTSD is so severe he lives in the crawlspace of his home — on a weekly basis for a year before reimbursement arrived.
"They couldn't tell me, they couldn't tell him, why they weren't paying," said Ray. "They pay sporadically. There's no rhyme or reason to it."
She took her complaints to Colorado U.S. Sen. Michael Bennet, whose office was able to help recoup some of the $12,000 she was owed, and get reimbursements flowing again for a while, but Ray said she was forced to make the difficult decision to stop accepting new Vet Choice clients at the end of 2017.
"So many veterans are getting referred to Choice, and so many are getting turned down because ... a doctor or psychologist has to say. 'Sorry, I no longer take Veterans Choice because I don't get paid,'" Ray said.
And when the government doesn't pay, it's ultimately the veterans who do.
"These guys sign up, go and serve their country and they come home and this happens. They feel betrayed, handed off by the VA, and it compounds their PTSD," Ray said.
Despite major systemic problems, the damning federal review and ongoing audit, Health Net Federal Services was awarded — and on Jan. 1 began running — the government contract running Tricare West, the region's other major manager of veterans health benefits.
Ray said she's lost sleep over it.
"A lot of my patients are Tricare, so, yes, I am worried," Ray said. "My big question to Health Net is, where is the money going if it's not going to providers? This is hundreds of thousands of dollars. But we're never told, and we can't ask questions."
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