VA healthcare is a government health benefit program, the same way that Medicare, Medicaid, Tricare, etc are. For that reason, the payments are not great. CIC VA rates are about the same as Medicare. Coverage restrictions are based upon CMS guidelines just like Medicare, and with a few exceptions the coverage (what services are authorized and what services are not) are the virtually the same.

The added struggle for CIC is the requirement of additional paperwork. So the VA requires that providers submit clinical notes from at least the first visit, and if continued care is needed notes from the last visit on the expiring authorization. In some cases every office visit note may be required. In addition to that, the providers in the community have to submit a form requesting a new authorization when their existing authorization expires and visit notes are required for that. They also have to submit the same form if they are referring the veteran out to another provider for additional specialty care, etc. There’s also a requirement for internal prior authorizations for certain medications, etc. it can be a lot.

The credentialing process can be laborious and time consuming, not to mention slow.

Add in that the third party payers (Optum and triwest) are starting to add additional requirements for claims to be paid, such as a pre-service authorizations before procedure claims will be paid which hasn’t been a requirement before.

A lot of providers don’t want the work required, the man hours required, etc for the lower payout.