Community Care in Crisis
A personal experience with a Community Care problem impacting me and thousand of veterans.
I am experiencing an issue with the Physical therapy referral from Harold Simmons Cancer Center. The surgeon referred me for 12 weeks of phyical threapy, three times per week.
When the PT received the authorization, it was limited to 15 treatments. I called community care and was initially told "TriWest" would only approve 15 treatments.
I called TriWest, and they do not authorize treatments. It is done by my local CC.
I called back, and the representative said she misspoke. She should have said TriWest would only pay for 15, and if I need more at the end of 15, the surgeon has to make a new referral. Doing it this way would be unnecessary and create an additional workload for everyone who is already over-tasked.
I asked what rule they were following, and she said they follow The VA's Standardized Episode of Care (SEOC). I then checked with SEOC and TriWest (about only paying for 15).
The local community care is not following SEOC or TriWest. This is what I found, and I'm unsure where to go from here.
---------------- Seoc ---------------
The VA's Standardized Episode of Care (SEOC) for physical therapy doesn't specify a set number of treatments. The VA's goal is to deliver the number of treatments recommended in the referral authorization to every veteran.
--------------- TriWest -------------
TriWest generally covers medically necessary rehabilitation therapies, such as physical therapy, but the specific number of treatments covered can vary.
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As a veteran with a presumptive condition - stage 3 colon cancer. I want to focus on rehab and not ask the surgeon, PMR, and CC to re-do a consult. The extra time and delays caused unnecessary stress.
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