I recently returned from the HCAOA annual conference, where I had the pleasure of representing Paradigm and attending many impactful sessions. It was great to meet so many of Paradigm’s providers and partners in person, as well as to connect with both new and established businesses in the space. Paradigm proudly sponsored an HCAOA breakout session led by Doug Robertson, where panel participants spoke about the ins and outs of working with Optum and Triwest. I left with insightful new takeaways and reaffirmed best practices, which I’m excited to share:
Session Takeaways
1. Know the Role of Third-Party Administrators vs. the VA
Understanding the distinct responsibilities of TriWest, Optum, and the VA itself is critical. Third-Party Administrators (TPAs) like TriWest and Optum handle contracting, credentialing, and payments for providers, establishing a network of community care providers that serve veterans. However, the VA Medical Centers (VAMCs) have the final authority in choosing providers and approving services. The VA sets care standards, assigns hours, and approves rates based on veterans' needs.
Providers should be aware of these roles to effectively balance relationships between VA staff, TPAs, and veterans, knowing who to connect with to address specific concerns.
2. Network Utilization and Communication
TriWest and Optum work closely with VAMCs to ensure that the full network of credentialed providers is accessible to veterans. This includes emphasizing the use of the entire provider network over more restricted, local lists. Although TPAs aim to increase utilization of all networked providers, local VA offices often have lists of preferred providers or established relationships.
To maximize your visibility and potential for referrals, it is recommended that providers engage with VA patient advocates, who can champion the veteran’s choice of a specific provider within the system.
3. Update Service Area Coverage and ZIP Code Information
Agencies typically cover a broad array of ZIP codes and territories, making it crucial for VAMCs to know the service areas of each provider. TriWest and Optum are in the process of developing tools that will allow providers to update their service areas by ZIP code, making it easier for VAMCs to access accurate service information. TriWest’s tool is expected to roll out in early 2025, while the tool release date from Optum is still pending.
This increased transparency can more effectively align your business with VA staff, ensuring that veterans have timely access to care within their local areas.
4. Leverage Patient Advocates
Patient advocates within the VA serve as critical allies for veterans, especially when a veteran has a preferred care provider. If a veteran wishes to work with a particular agency that isn’t initially recommended by the VA, patient advocates can facilitate this choice. Leveraging these advocates can help agencies foster long-term, trusted relationships with veterans while also making sure that care remains centered on the veteran’s preferences.
5. Stay Engaged with Resources and Training
Attending regular trainings, from webinars to educational sessions, can keep providers informed of any updates to processes or requirements. Engaging with these resources allows agencies to stay up to date, maintain compliance, and understand the latest industry best practices, all of which are needed to provide and continue providing the best of care.
6. Maintain Up-to-Date Credentialing
Keeping your agency’s credentials current is essential for ensuring continuous service and eligibility for referrals. TPAs advise agencies to renew credentialing every 2.5 years, as well as for agencies to immediately notify TPAs of operational changes like relocations or acquisitions. Maintaining up-to-date credentials reassures the VA and TPAs of an agency’s readiness, reliability, and commitment to quality care.
Leveraging Paradigm’s Expertise for Efficient TPA Collaboration
Navigating the VA network requires a steady pulse on updates and opportunities to streamline care. Paradigm is dedicated to helping providers understand the evolving needs of the VA system. We stay connected with TriWest and Optum to keep you aware of their latest developments.
Starting in 2025, Paradigm will be offering regional training sessions tailored to specific markets, helping providers tap into localized resources and information that can make all the difference in a complex network like the VA. These sessions will cover operational adjustments, effective use of TPA tools, and strategies for better regional alignment with VA needs.
At Paradigm, we’re here to support you through the complexities of VA and TPA processes, helping your agency focus on what matters most: delivering exceptional care to those who have served.
About the Author: Melissa Mendez has spent the last decade educating the home care industry. She began her career at Home Care Pulse, developing crucial training and marketing materials for home care professionals. Now at Paradigm, she leverages her deep understanding of post-acute care to create impactful educational content and marketing strategies, empowering home care agencies to navigate VA and Medicaid complexities and expand their operations effectively.
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