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


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 reprice 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")

How to identify Choice utilization in PIT tables

There are a few ways to identify Choice utilization in the CDW PIT tables.

  • 1. Use the Third Party Administrators' (TPA) tax identification numbers. Look for TriWest and HealthNet as billing providers.
  • 2. The variable PatientControlNumber in [CDWWork].[PIT].[PITCliam] will contain the string 'CHO' in it, e.g. “ where PCN like %CHO% ".
  • 3. ETLBatchID is the best one, but there are multiple values:
    • a. ETLBatchID - “ like VACDB% ” will give you all Choice claims that were processed in FSC/Plexis system. This is the largest bucket.
    • b. ETLBatchID – “ like EXPWK% ” will give you almost all Choice claims for expedited claims. There are 57 weeks, the only one that will be missing is week one. For that one you need to use ETL BatchID “ like %VCB ”. This is the second largest bucket.
    • c. There will be Choice claims coming from FBCS, for those claims that were processed by Voucher examiners before 10/01/2016. Those can be identified by special provider category or authorization. This is the smallest bucket.

Note: Items listed in quotes (e.g., " where PCN like %CHO% ") are T-SQL search strings.

Exploratory Work

We extracted FY15 professional and institutional PIT claims data for cataract surgeries using the CPT codes 66982 and 66984. To illustrate how we joined the PIT tables together, we have created two Excel files. One is for the professional component, and the other is for the institutional component.

PIT Professional Claims

PIT Institutional Claims

The PIT data, along with the metadata for these tables, can be found on the VHACDWA01.VHA.MED.VA.GOV server in VINCI. Specifically, these Excel files are adapted from the metadata from [CDWWork].[Meta].[DWViewField]. Our Excel files contain information as of October 2018. For the most up-to-date variables and variable descriptions, please check the original metadata.

Description: Each tab in the Excel files represents a particular PIT table. The yellow rows denote the linking keys between each subsequent table. For the professional component, the orange rows are the variables we chose to keep for our analysis. For the institutional component, this is denoted by the blue rows.

Assumptions: In an earlier analysis, we extracted data using three filters:

  • 1. WHERE CurrentFlag = “Y” AND
  • 2. ClaimStatus = “Accepted” AND
  • 3. PayFlag = “Y”

This will return current, accepted, and paid claims. If you are interested in looking at acted upon utilization and not only paid claims, you might want to consider leaving out the third filter, PayFlag = “Y”. However, this may leave you with duplicate records. Keep in mind that PIT only has records on which there has been some action. If there was no action on the claim, then it will not show up in PIT.

Caveats: Please note that the PITProcedureCode variable can be messy. In our analysis that focuses on using cataract surgeries, we only found three variations, “66982”, “66984”, and “66.984” when we intended to search for CPTs 66982 and 66984. We assume that “66.984” is a data entry error for “66984”. Thus, it was relatively easy to re-code “66.984” to lump with the “66984” records. However, users should be aware that the data could be more complex when one expands to other procedure codes that might contain typos and/or other variations.

Additionally, we found that only ~ 40-50% of institutional and professional claims from FY15-18 have non-missing SSN and PatientICN in the [CDWWork].[SVeteran].[PITPatient] table. This figure is for all claims and not only cataracts. However, we discovered that the MemberID variable in SVeteran.PITPatient actually contains the patient’s SSN as well. This variable is rarely missing. Thus, MemberID is recommended to be used as a patient identifier.

These are our first steps in extracting and exploring the PIT data. We are aware there may be duplicates, and we are still working on figuring out how to resolve that issue.

If you have insight/tips to share regarding the PIT data, please feel free to email us.

Last updated: January 8, 2019