- Participating Physician Groups (PPG)
(does not apply to HSP)
The Veterans' Administration (VA) is a provider of care rather than an insurance program to which Congress granted the following rights:
Right to Require Payment
When participating providers must pay the VA for services, the VA has the right to require payment from private insurers, to the extent that benefits are available, for services they provide to qualified veterans for non-military service-related disabilities. This means that if the participating provider authorizes a service that has been or will be performed by the VA, and the participating provider would ordinarily pay for the service, the participating provider also has to pay the VA. The plan does the same regarding services for which it ordinarily makes payment
If a concern arises over whether an illness or injury is due to a military service-connected disability, the VA's determination is accepted. Federal law provides that the VA determination is not subject to review, even in the courts. On request, the VA must provide documentation to substantiate its decision.
Providers must conduct administrative procedures as usual when the VA provides services to a member. The members should seldom require services from a VA participating provider. When it does happen, and the services have been authorized and referred, or a legitimate emergency necessitates services that were authorized after the fact, the participating provider should carry out all administrative procedures throughout the entire process in the usual manner as if the VA were not involved
Assignment of Benefits
The VA sends the insurer a copy of assignment of benefits. When a member is treated by the VA, federal regulations state that the VA must immediately send the insurer a copy of an assignment of benefits (this might be sent to either the participating provider or the plan). The VA cooperates with requests for medical records. Charges are based on stipulated formulas, but the VA does not expect to receive payment greater than would ordinarily be paid to other participating providers in the geographic area. The VA may receive a Medicare payment for services rendered.