HERC: Veterans Choice Program - Program Integrity Tool (PIT)
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Veterans Choice Program - Program Integrity Tool (PIT)

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Reconciliation and Auditing: Program Integrity Tool (PIT)

It is our understanding that the Program Integrity Tool (PIT) is an IBM product purchased by VA that aggregates many sources of data and allows for checking for fraud, waste, and abuse. This data source has an elevated privilege and operations users can request access via ePAS. It appears that starting in FY2016, Choice data began bypassing FBCS and residing in the PIT. By June 2017, no Choice stays are found in FBCS.

PIT went online in 2013 and FBCS claims in PIT can have a claim create date back to 2013. Providers and TPAs can submit older claims so you can see a claim submitted in 2018 with a date of service as far back as the start of PIT. We believe the data flow into PIT begins with non-VA providers rendering services and submitting claims to TPAs. They submit EDI837 files to EMDEON and from there it goes into ERepos in VA, then to FPPS to FBCS and finally to PIT. Within each step of data processing, the potential for data loss is great. In one instance, a TPA was not passing any of the Service Facility NPIs to VA for a few years so for those claims, it looked like the provider was the TPA; which is incorrect. There are known issues with the PIT mappings for Rendering Provider NPI and Service Facility NPI.  Efforts have been made to correct some such errors in the past and more checks are in place to ensure such errors are not allowed moving forward.

VA payments to non-VA providers are limited to Medicare payments, by law. In general, providers can bill VA whatever amount they feel like and it is up to the TPA, VA, or FSC to ensure the billed amount is correct, prior to releasing payments. Choice and PC3 payments should be based on the Medicare rates times the CLIN (which can be 85%, 100%, 150%, 250%, and a few other multipliers, based on the provider contracts) but the price validation was not set up during the initial processing of Choice and PC3 claims, so VA paid the billed amounts on submitted claims. The result is that for a single CPT code, you may find different payments which vary from a couple hundred dollars to tens of thousands of dollars. Since the onset of Choice there have been efforts to go back to repice and collect money from overpayment to providers but it is a time-consuming effort and is being remedied moving forward.

The PIT Domain was released into the CDWWork environment on September 25, 2018. The domain has 66 views, 27 dimensions, and 39 fact views. The PIT domain contains VA claims that have been processed through the PIT, including but not limited to Choice claims. CDW documentation includes:

  • PIT Release documents (https://vaww.cdw.va.gov/metadata/Metadata%20Documents/Forms/AllItems.aspx?RootFolder=/metadata/Metadata%20Documents/PIT%201.0&FolderCTID=0x0120007BD83FE7EC890F42B79E1DA11A744B1E&View=%7bA9968955-5886-4DEC-A6BF-0CB219ADD175%7d)
  • CDW Metadata Report (https://vaww.cdw.va.gov/metadata/_layouts/15/ReportServer/RSViewerPage.aspx?rv%3aRelativeReportUrl=/metadata/Reports/Metadata%20Report.rdl&Source=http%3a//vaww.cdw.r02.med.va.gov/metadata/Reports/Forms/AllItems.aspx&DefaultItemOpen=1)
  • How to Get Access (https://vaww.cdw.va.gov/Pages/CDWHome.aspx) (select "Data Access Information")

Last updated: October 1, 2018