B-92679, JUNE 30, 1967, 46 COMP. GEN. 895

B-92679, JUNE 30, 1967, 46 COMP. GEN. 895

VETERANS - MEDICAL SERVICES - PRIVATE - PROCEDURE THE SIMPLIFICATION OF THE PROCEDURE FOR PROVIDING FEE-BASIS OUTPATIENT TREATMENT AND OTHER MEDICAL SERVICES TO VETERANS WITH SERVICE-CONNECTED DISABILITIES BY FURNISHING ELIGIBLE VETERANS WITH IDENTIFICATION (ID) CARDS FOR PRESENTATION TO A PHYSICIAN IS APPROVED, THE ID CARD TO CONTAIN EXPIRATION DATE, THE VETERAN'S NAME, SIGNATURE, CLAIM NUMBER AND DISABILITIES, TOGETHER WITH THE DOLLAR LIMITATION ON MEDICAL COSTS AND BILLING INSTRUCTIONS, THEREBY PERMITTING MEDICAL COSTS TO BE CHARGED TO THE APPROPRIATION CURRENT AT THE TIME AN INVOICE IS ACCEPTED BY A QUALIFIED EMPLOYEE, RESULTING IN SAVINGS TO THE GOVERNMENT THROUGH THE ELIMINATION OF THE OFFER AND ACCEPTANCE CONCEPT UNDER THE OLD PROCEDURE WHICH CREATED AN OBLIGATION ON THE GOVERNMENT TO PAY AT THE TIME THE MEDICAL SERVICES WERE PERFORMED.

TO THE ADMINISTRATOR, VETERANS ADMINISTRATION, JUNE 30, 1967:

REFERENCE IS MADE TO YOUR LETTER OF MAY 17, 1967, ASKING OUR CONCURRENCE WITH A PROPOSED REVISED PROCEDURE FOR PROVIDING FEE-BASIS OUT-PATIENT TREATMENT AND OTHER MEDICAL SERVICES TO VETERANS WITH SERVICE-CONNECTED DISABILITIES. IT IS STATED THAT THE NEW PLAN WOULD ELIMINATE A SUBSTANTIAL AMOUNT OF PAPERWORK THEREBY REDUCING COSTS AND THAT BETTER SERVICE WOULD BE PROVIDED TO ELIGIBLE VETERANS IN THAT THEY WOULD BE PROVIDED IMMEDIATE CARE BY THE VETERAN'S PERSONAL PHYSICIAN WITHOUT THE DELAY INCIDENT TO THE PHYSICIAN REQUESTING AN AUTHORIZATION FOR THE TREATMENT, THE PREPARATION OF THE AUTHORIZATION AND THE TIME LOST IN THE COMMUNICATION PROCESS.

IT IS OUR UNDERSTANDING THAT UNDER CURRENT PROCEDURES EACH VETERANS ADMINISTRATION (VA) STATION MAINTAINS A ROSTER OF PARTICIPATING FEE BASIS PHYSICIANS AND A LISTING OF VETERANS AUTHORIZED TO RECEIVE CARE. AT THE BEGINNING OF EACH FISCAL YEAR, EACH STATION ESTIMATES THE NUMBER OF VISITS THAT EACH VETERAN ON THE LIST WILL MAKE TO A PHYSICIAN ON THE ROSTER. THE VA INFORMS EACH PHYSICIAN OF THE NAMES OF VETERANS ASSIGNED TO HIM FOR TREATMENT AND THE NUMBER OF VISITS EACH VETERAN IS AUTHORIZED TO MAKE. BASED ON THESE ESTIMATES, EACH STATION AT THE BEGINNING OF EACH FISCAL YEAR OBLIGATES SUFFICIENT FUNDS TO PAY FOR THE ESTIMATED AUTHORIZED VISITS.

THEREAFTER THE STATION REVISES MONTHLY ITS ESTIMATE OF THE NUMBER OF AUTHORIZED VISITS AND ADJUSTS THE AMOUNTS OBLIGATED AS (1) VETERANS ARE ADDED TO OR REMOVED FROM THE LIST, (2) DIAGNOSIS OF THE CONDITIONS OF THE VETERANS BY THE PHYSICIANS CHANGES THE NUMBER OF VISITS REQUIRED, OR (3) VA IS INFORMED THAT A VETERAN FAILED TO KEEP HIS PHYSICIAN APPOINTMENTS.

UPON RECEIPT OF AN INVOICE FROM A PARTICIPATING PHYSICIAN, THE STATION NOTES WHEN THE TREATMENT WAS GIVEN, LIQUIDATES THE OBLIGATION RECORDED FOR THE VISIT AND CHARGES THE APPROPRIATION CURRENT AT THE TIME THE SERVICE WAS RENDERED. IT IS STATED THAT MOST PHYSICIANS SUBMIT THEIR INVOICES FOR PAYMENT ABOUT 3 MONTHS AFTER SERVICES ARE RENDERED, HOWEVER, IN SOME CASES A YEAR OR MORE MAY ELAPSE BEFORE THEY SUBMIT THEIR BILLS. AS A RESULT, AT THE END OF EACH FISCAL YEAR A CONSIDERABLE AMOUNT OF FUNDS MUST BE OBLIGATED TO PAY FOR AUTHORIZED VISITS BY THE VETERANS FOR WHICH THE PHYSICIANS HAVE NOT YET BILLED THE VA.

UNDER THE PROCEDURE NOW PROPOSED ELIGIBLE VETERANS WILL BE FURNISHED WITH IDENTIFICATION (ID) CARDS WHICH WILL BE PRESENTED TO A PHYSICIAN WHENEVER THE VETERAN BELIEVES THAT HE NEEDS ATTENTION FOR A SERVICE CONNECTED DISABILITY. THE ID CARD WILL CONTAIN THE VETERAN'S NAME, CLAIM NUMBER, THE VETERAN'S SIGNATURE FOR IDENTIFICATION PURPOSES, A BRIEF DESCRIPTION OF THE DISABILITIES WHICH MAY BE TREATED AT VA'S EXPENSE, A DOLLAR LIMITATION ON THE COST OF MEDICAL SERVICES NORMALLY OBTAINABLE PER MONTH, AN EXPIRATION DATE AFTER WHICH THE CARD WILL BE VOID, BILLING INSTRUCTIONS TO THE PHYSICIAN AND CERTAIN OTHER RELATED INFORMATION.

IT IS EXPLAINED THAT---

IN OPERATIONS, THE VETERAN PRESENTS THE ID CARD TO HIS PERSONAL PHYSICIAN, WHO WITHOUT ANY FURTHER INSTRUCTIONS FROM THE AGENCY, WILL RENDER THE MEDICAL SERVICES AND THEN BILL THE AGENCY IN ACCORDANCE WITH THE BILLING INSTRUCTIONS. THE BILL IS APPROPRIATELY REVIEWED TO DETERMINE WHETHER THE AGENCY SHOULD ACCEPT LIABILITY FOR THE COST OF THE SERVICE. THE REVIEW COMPREHENDS A QUASI-ADJUDICATIVE PROCESS, IN THAT THE REVIEWING PERSON MUST FIND WHETHER THE VETERAN IS ELIGIBLE FOR THE TREATMENT, MUST DETERMINE WHETHER THE TREATMENT WAS NECESSARY AND PROPER IN THE LIGHT OF THE DISABILITY RECORD AND IF IN ORDER, APPROVE THE TREATMENT WHICH CONSTITUTES ACCEPTANCE BY THE AGENCY OF LIABILITY FOR THE ALLOWABLE CHARGE FOR THE TREATMENT. THE FACT OF THIS DETERMINATION (ADJUDICATIVE ACTION) IS EVIDENCED BY A SIGNED CERTIFICATION (RECEIVING REPORT) ON THE INVOICE. THE INVOICE IS THEN PROCESSED FOR APPROVAL BY AN AUTHORIZED CERTIFYING OFFICER. FOR FUND CONTROL AN ESTIMATED AMOUNT IS RESERVED FROM THE ALLOTMENT AT THE BEGINNING OF EACH MONTH TO COVER INVOICES EXPECTED TO BE RECEIVED DURING SUCH MONTH. AT THE END OF THE MONTH THIS ESTIMATED FIGURE IS CONVERTED TO THE VALUE OF INVOICES ACTUALLY RECEIVED. THIS FIGURE, THE VALUE OF INVOICES ACTUALLY RECEIVED FOR THE MONTH, IS REPORTED AS THE OBLIGATION AGAINST THE APPROPRIATION CURRENT FOR THE MONTH. FUNDS NEEDED WILL BE BUDGETED AND APPROPRIATIONS REQUESTED ON THAT BASIS (VALUE OF INVOICES RECEIVED). UNDER CURRENT PROCEDURES THE AUTHORIZATION FOR TREATMENT IS CONSIDERED AS BEING AN OFFER BY THE GOVERNMENT TO CONTRACT ON THE BASIS THEREIN INDICATED AND THE PERFORMANCE BY THE PHYSICIAN CONSTITUTES AN ACCEPTANCE OF THAT OFFER THUS CREATING AT THAT TIME AN OBLIGATION ON THE PART OF THE GOVERNMENT TO PAY FOR THE SERVICES. UNDER THE PROCEDURE NOW PROPOSED THE PRESUMPTION IS THAT THE VA IS NOT LIABLE FOR THE COST OF THE TREATMENT UNTIL THE INVOICE HAS BEEN ACCEPTED BY A QUALIFIED EMPLOYEE. AS A RESULT, THE COST IS CONSIDERED CHARGEABLE TO THE APPROPRIATION CURRENT AT THE TIME THE INVOICE IS RECEIVED. IT IS URGED THAT THE ACCEPTANCE OF THE INVOICE CONSUMMATES THE AGREEMENT TO PAY THE ALLOWABLE FEES AND SUCH INVOICE CONSTITUTES THE DOCUMENTARY EVIDENCE OF THE OBLIGATION REQUIRED BY 31 U.S.C. 200 (A).

AS INDICATED IN YOUR LETTER WE HAVE HELD THAT THE FISCAL YEAR APPROPRIATION CHARGEABLE WITH THE COST OF EMERGENCY HOSPITALIZATION OR MEDICAL AND DENTAL TREATMENT WITHOUT PRIOR AUTHORIZATION IS THAT APPROPRIATION CURRENT AT THE TIME THAT THE CLAIM FOR REIMBURSEMENT IS APPROVED. B-92679, JULY 24, 1950. ALSO, IN B-133944, JANUARY 31, 1958, THERE WAS CONSIDERED THE QUESTION AS TO WHICH FISCAL YEAR APPROPRIATION PROPERLY SHOULD BE CHARGED WITH THE COST OF FILLING PRESCRIPTIONS WRITTEN BY CERTAIN DESIGNATED PHYSICIANS AND DENTISTS. IN THAT DECISION WE STATED THAT---

IT ADMITTEDLY IS DIFFICULT TO ESTIMATE THE COST OF PRESCRIPTIONS WHICH MIGHT BE ISSUED IN ANY MONTH OR YEAR BY THE DESIGNATED PHYSICIANS AND DENTISTS THROUGHOUT THE UNITED STATES. ALSO, THE SEGREGATION OF THE PRESCRIPTIONS WHEN RECEIVED BY THE FISCAL YEARS DURING WHICH THEY WERE FILLED WOULD ENTAIL CONSIDERABLE EXPENSE ESPECIALLY DURING THE FIRST QUARTER OF EACH FISCAL YEAR. IN VIEW THEREOF AND ESPECIALLY SINCE THE FUNDS HAVE BEEN, AND APPARENTLY WILL CONTINUE TO BE, BUDGETED AND APPROPRIATED ON THAT BASIS, WE DO NOT FEEL REQUIRED TO OBJECT TO THE OBLIGATION OF THE APPROPRIATION ON A MONTHLY BASIS TO COVER THE MONTHLY BILLS REQUIRED UNDER THE ANNUAL CONTRACTS WITH THE PHARMACEUTICAL ASSOCIATIONS, PROVIDED THAT THIS PROCEDURE IS FOLLOWED CONSISTENTLY AND THE FUNDS ARE BUDGETED AND APPROPRIATED ON THAT BASIS.

SINCE THE CIRCUMSTANCES CONSIDERED IN THE ABOVE-QUOTED DECISION ARE SIMILAR TO THOSE HERE INVOLVED, THE NEW PROCEDURE APPARENTLY WILL RESULT IN CONSIDERABLE SAVINGS TO THE GOVERNMENT, AND FUNDS WILL BE BUDGETED AND APPROPRIATIONS REQUESTED ON THE BASIS OF INVOICES RECEIVED WE WILL RAISE NO OBJECTION TO THE OBLIGATION OF FUNDS IN THE MANNER SUGGESTED IN YOUR LETTER.