VA Seeking Refunds for Past CHAMPVA Claims
The U.S. Department of Veterans Affairs (VA) announced it aims to recover more than $41 million in “overpaid claims” paid to physicians and other health care professionals and entities through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) program.
Texas Medical Association staff caution that physicians receiving CHAMPVA refund requests should take several steps to satisfy the VA request without immediately losing payment for care already delivered:
- Confirm the legitimacy of the request letter. As refund letters typically come from third-party companies, a practice may call CHAMPVA and ask them if the third-party company is one they contracted with to collect the overpayment;
- Check the letter for details on how to appeal, including any payment or appeal deadlines; and
- Check the letter for information about which insurer VA says is responsible for payment.
From there, physicians can choose one of two actions. If it appears the alleged overpayment has been identified in error, start the appeal process to try to keep the CHAMPVA payment already received. If not pursuing an appeal – or if an appeal is ultimately denied – refund the overpayment to VA and seek payment from the insurer VA says is responsible for payment. For a physician seeking payment from that insurer, TMA recommends including, as part of that request, the initial CHAMPVA explanation of benefits and any information from VA indicating that the insurer is the proper payer, especially if the filing deadline has passed.
For assistance with CHAMPVA refund requests or other payment matters, contact TMA’s Physician Payment Resource Center.
More on HCSC Acquisition of Cigna MA
Can this get anymore confusing?
🏢 What is HCSC?
Health Care Service Corporation (HCSC) is:
The largest customer-owned (non-investor-owned) health insurer in the U.S.
A licensee of the Blue Cross and Blue Shield Association (BCBSA).
It operates five Blue Cross Blue Shield health plans:
Blue Cross and Blue Shield of Illinois
Blue Cross and Blue Shield of Texas
Blue Cross and Blue Shield of New Mexico
Blue Cross and Blue Shield of Oklahoma
Blue Cross and Blue Shield of Montana
🔗 What is the Relationship Between HCSC and BCBS?
BCBS is a national brand and association, not a single company. It licenses its brand to independent regional companies.
HCSC is one of those companies, and it owns and operates the BCBS plans in the five states listed above.
So, when someone has BCBS of Illinois, for example, their insurance is actually managed and provided by HCSC.
Acquisition Completed March 19, 2025.
It has been stated:
- Members will have the same plan, benefits, and network structure.
- No changes are expected for 2025.
- Members should not expect any changes in coverage of out-of-pocket cost.
- And the one thing we hope will change is, BCBS says we can still expect the same level of service.
Cigna Commercial REMOVING Multiple Services from Their Pre-Cert List.
Many services will no longer require prior authorization (i.e. Precertification) for Cigna Commercial, beginning May 31, 2025.
Please note, however, that removal from precertification is not a guarantee of payment. Codes may be subject to standard code editing, benefit plan exclusions, and post-service review for coverage.
HEADS UP! Rider 32 Transition
Effective September 1, 2025
Texas Health and Human Services Commission will implement Rider 32, which will transition Medicaid only services for dually eligible members from a fee-for-service model to a managed care delivery system.
This change affects services provided to members who are eligible for both Medicaid and Medicare. It applies only to those Medicaid services not covered by Medicare.
Providers will bill the MCO for Medicaid wrap-around services provided to dually eligible members.
Wrap-around services include all Medicaid services not covered by Medicare. They are limited to those already covered under managed care for Medicaid-only members.
UHC Claims their new API makes work easier.
UnitedHealthCare’s Application Program Interface (API) is a free digital solution that automates everyday work.
Benefits of using API
- Reduces phone calls and paper
- Automates transactions on your timetable
- Distributes data faster to where you need it
- Get real‑time information
- Supports standard formats and compatible with new technology
- Maximizes efficiency and productivity through workflow integration
Why add API to your practice?
- Flexibility: Allows you to choose the data and API that fit your needs.
- Automation: Incorporates seamlessly into your workflow.
- Security: Ensures data is accessed and transferred securely
Humana
TIPS, TRICKS AND HELPS
PREAUTHORIZATON LISTS (PAL):
Lists of services and medications effective July 1, 2025, that may required preauthorization for members with Medicaid, Medicare Advantage, and dual Medicare-Medicaid coverage are now available.
Easily determine if a prior authorization is required with Humana’s search tool. Search by Current Procedural Terminology (CPT®) codes, procedures or generic drug name(s). Remember to verify benefit coverage in Availity Essentials
Availity Essentials Introduces Check Claim Status Feature:
Availity has enhanced its Eligibility and Benefits (E/B) page by adding a Check Claim Status feature.
What you can expect:
- Improved efficiency and accuracy: The check Claim Status tool pre-populates your patient’s information, ensuring accuracy.
- Time savings: You can access claim status with one click- saving time and effort
Separate Services, Same Date of Service
With health plans increasingly adopting payment protocols that hinder physicians from providing multiple services on the same day – despite previously covering such services – delegates adopted policy calling on TMA to “advocate for legislation or regulation that would prevent Medicaid and commercial payers from denying payment for distinct, separate services provided on the same day.”
Delegates agreed with physicians’ concerns that these payer practices often force patients to forego care.
“This especially hurts patients who either have to travel long distances to see their physician or have transportation issues that prevent them from making multiple trips,” Odessa allergist and immunologist Vivek Rao, MD, wrote in online testimony on behalf of the Lone Star Caucus
Other measures adopted by the house to eliminate payment-related barriers to patient care direct TMA to pursue state-level legislation or regulation that:
- Prohibits insurers, plan sponsors, third party administrators, and other contracted identities from recouping previously paid claims due to retroactive termination of patient coverage;
- Imposes payer communication standards – with penalties – that provide patients, physicians, and others with timely access to a live representative; and
- Expedites prior authorization approvals for hospice care in emergency and acute care settings, eliminates deductibles for hospice care, and provides clear disclosures detailing hospice care benefits in policy documents as well as online.
Mandated CME Requirements Are Shifting
A recent reorganization of Texas Medical Board (TMB) rules has removed certain universal CME obligations. The removal of universal CME requirements could result in a lighter load for physicians but may make it more challenging to determine what is required and when.
Please click the button below to view the entire article from Texas Medical Assocation.
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