Patient-Centered Community Care (PC3) and Veterans Choice Program (VCP) for Health Net Federal Services (HNFS)

Executive Summary

Cognitive Medical Systems implemented the Federal Information Security Management Act (FISMA)-compliant IT hosting environment, developed data integration solutions for healthcare administration and claims management systems, and developed custom web-based applications used by HNFS to manage the Department of Veterans Affairs (VA) PC3 and VCP (also known as Choice) programs. VA’s PC3 and Choice programs provide private healthcare to compliment the VA healthcare system.

Challenges

VA operates the largest integrated healthcare system in the United States, providing care at 1,250 facilities for over 9 million Veterans nationwide. VA awarded the PC3 program to HNFS in 2013 to augment services available at local VA facilities by outsourcing specialized care to providers in the community. At the outset of the contract, the volume of Veterans referred to providers outside of VA was anticipated to be low. However, due to the Veterans Access, Choice, and Accountability Act passed by Congress and mounting pressure on VA to address long wait times, the Choice contract was awarded to HNFS in 2014 to expand private healthcare services available to Veterans. The volume of Veterans referred to HNFS for private healthcare surged exponentially and remained much higher than initial requirements due to the high demand for Veteran healthcare services outside of VA facilities.

How We Helped

Cognitive successfully implemented the FISMA-compliant PC3 hosting environment, with mission-critical healthcare administration systems and custom data integration solutions, in the Amazon Web Services (AWS) GovCloud within the aggressive 90-day transition-in period. Cognitive worked very closely with HNFS business leaders to develop custom web-based applications to address unique PC3 and Choice business requirements around appointments, medical documentation administration, and medical claims processing. As the program volumes surged, the AWS GovCloud environment gave Cognitive the flexibility needed to address hosting infrastructure capacity issues quickly and cost effectively.

Custom applications and system integrations:

  • Built a “systems environment” in the AWS GovCloud as part of the Health Net Integrated Management System (HNIMS)
  • Built and maintained a web-based provider search tool, the HNIMS Provider Directory, which integrated with Google Maps and American Medical Association (AMA) application programming interfaces (APIs)
  • Developed an integration service between the Availity Provider Portal and the Quantum Choice (QC) claims management system
  • Developed an integration service for paper referral/authorizations with optical character recognition (OCR), parsing, and automatic API calls to claims management system
  • Developed an integration service between the QC claims management system and the InContact Auto Dialer phone system
  • Configured, customized, integrated, and tested the primary information systems, which manage all referral, authorization, consult, claims processing, and medical documentation for the program

“You are all doing better than well. The communication, the organization and the teamwork is allowing us to continue to check more and more boxes as we press on.”

—Kelly Tan, Sr. Business Systems Analyst, HNFS/Centene

Outcomes

Cognitive has provided IT hosting and custom software application services for HNFS in support of the VA PC3 and Choice programs in the AWS GovCloud environment since 2013, with contract completion expected in September 2021. Program highlights include:

  • Maintained uptime of 99.96% from 2014 to present
  • Scaled from an initial 100 users to 1,500 in 30 days, with 4,200 concurrent users
  • Processed 20,880,649 claims from 2014 to present
  • Successfully maintained security requirements: Defense Information Security Agency (DISA) Security Technical Implementation Guides (STIG); Nessus Pro Vulnerability Assessment Scanner; and Security Content Automation Protocol (SCAP) benchmarks, verified through third-party audits

Cognitive is committed to going beyond contractual requirements to provide excellent customer support at all levels of the organization, including help desk support for end users and business solution support for senior leadership. As an expert in the AWS GovCloud hosting space, Cognitive continues to support HNFS and its new parent company, Centene, with its existing Federal programs and will continue to support future opportunities.

“Overall security program for the PC3 environment is well structured and executes security best-practices in the overall design architecture. Cognitive has developed and implemented a security program with mature processes and procedures for incident response, audit/log review, and continuity of operations. With senior leadership support, Cognitive has implemented necessary security requirements or performed remediations of identified vulnerabilities to achieve favorable attributes of a low-risk security posture.”

—Beacon Cloud Solutions Security Assessment Report July 2020


About PC3

To address an appointment backlog for VA care Congress passed the Veterans Access, Choice, and Accountability Act of 2014, which established the Choice Program.

Under the Choice Program, VA is required to authorize care outside of the VA if the Veteran is unable to get an appointment at a VA facility within 30 days or lives more than 40 miles away from the nearest VA medical facility.

Health Net and TriWest were selected to handle non-VA care for the Choice Program under the PC3 contract, which already supported purchased specialty care but was expanded to include the Choice Program.