Hello, everyone, hi, and thank you for coming today to see, to listen to our webinar, Across State Lines, Challenges in Medical Forensic Exam Payment and Reimbursement, Solutions for Clinicians and Survivors. Before we get started, I'd like to go over a couple of acknowledgments and disclosures. This webinar was supported by a grant awarded by the Office on Violence Against Women, the U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this presentation are those of the authors and do not necessarily reflect the views of the U.S. Department of Justice. And I'd like to say thank you to OVW for making this presentation happen today. For disclosures, this session's planners, presenters, and content reviewers have no relevant financial relationships with ineligible companies to disclose. To receive a certificate documenting your contact hours, you must complete the webinar evaluation. You will receive a certificate that documents the continuing nursing education and the contact hours for this webinar activity. We will be making that link to the evaluation available in your chat at the end of today's webinar. The International Association of Forensic Nurses is an accredited provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. My name is Corin Brezelik, and I'm a forensic nurse specialist with the International Association of Forensic Nurses. In my role, I provide training and technical assistance on the national safe protocols, the national IPV protocols, the national training standards, and topics related to payment for medical forensic examinations. I'd also like to introduce our host for the day, so it will be Carrie Canedo, and she will be monitoring the questions, the Q&A, and the chat responses. Learning outcomes, at the conclusion of this presentation, attendees will have an increased knowledge of strategies and resources that can be utilized to address issues that may arise when seeking payment and reimbursement for medical forensic exams conducted in one state when the sexual assault occurred in a different state. Addressing Sexual Assault Medical Forensic Exam Reimbursement. So, what brings us here today? We all know that payment for reimbursement for medical forensic exams in itself is challenging. However, navigating payment for medical forensic exams when the assault occurred across state lines presents a unique challenge for healthcare professionals and survivors. As dedicated sexual assault responders, healthcare clinicians, service providers, advocates, and nurses upholding a victim-centered and trauma-informed approach, we must ensure our survivor's safety, privacy, and well-being throughout the billing process. Medical forensic exams are essential not only for the health and healing of the survivor, but also for the criminal justice process. It is our responsibility to be well-equipped with the knowledge and strategies necessary to guide survivors through resolving these challenges. So, I'd like to start this webinar off with a couple of questions to generate some conversation. So, please feel free to place your responses in the chat. And if you would like to share and or comment throughout the webinar, we'll have you put those in there soon. So, the first question is, have you ever encountered challenges with receiving reimbursement for medical forensic exam when the assault occurred out of your jurisdiction, either out of county or out of state? And it looks like everyone has responded. So, we have almost half of you all here have said that you have had this issue. For those of you who responded, and if you would like to share too, you can also expand on this, but how did you navigate through that challenge? Did you have the necessary tools to navigate the challenge? Yes or no. But it looks like 83% of you all said no, you did not have the necessary tools, which is what I'm hoping we will be able to give you guys the resources and tools to be able to solve these particular issues. And then for those who responded, and please feel free to share in the chat, how did you navigate through that challenge? What did you do to be able to resolve it? Corinne, we have some great feedback happening in the chat. By tools means calling people on the phone and trying to explain what you're trying to do. Tools, are you asking on tools or if you can clarify that? I will say we'll be giving you tools as far as resources, who to reach out to when you are addressed with this challenge, and who you will be reaching out to get your questions answered. And we have a lot of responses coming. Yes, and some people have reached out to their state CDC, and they received guidance and assistance. That's another tool or resource. And then someone commented without a state resources, they're not always that interested in helping as we thought didn't happen in their state. You're absolutely correct. I've heard that comment before, and we're going to talk about that particular challenge too. And someone else responded, I got lucky and a person in our billing department had just moved from the state and had contacts that helped us figure it out. And without her, I don't know what I would have done. And to be honest, that is another very valuable resource. And that was our, that is your billing department. They are very valuable. Another one, I reached out to other things in the region and state for other things. Yes. And someone responded that New York state, yes, paid for the medical forensic exam that was provided in hospitals. And regardless of, yes, some states are very specific, and even in their statutes, they automatically take the responsibility. The next question we just already answered it, but you can answer A or B. Of those who had an issue and experiences, what was the outcome of that challenge? Was it resolved or unresolved? Two more answers in. So it looks a little over half responded so far. And almost a little, it looks like most of you all, 55%, it was resolved. But we also have a lot, 45% that was unresolved. And we're going to talk a little bit about that too. And while some of these, even through the scenarios that we'll go through and some of the challenges that come up, that sometimes they don't get resolved. But we'll talk about that and what to do in those cases when there isn't a resolution. Or let me say there isn't an immediate resolution. All right. Thank you all again for your responses and comments. It's always valuable to hear about the real challenges that you all are facing, navigating the reimbursement and payment process for medical forensic exams. And it can be difficult, especially when the assault occurred on, occurred across state lines or in another jurisdiction. In the upcoming slides, we will go over hypothetical scenarios where the assault happened in one jurisdiction and the exam was performed in another. First on this project, I found that while jurisdictions may differ, the decision-making process is generally the same. We will look at and discuss typical challenges and walk through the decisions for potential solutions. Based on your previous polling and responses, you might find that some issues, such as claim reimbursement, cannot be resolved without legislative changes. In those cases, understanding the decision tree can guide you on the best steps to take. Throughout this webinar, we'll have the chat open for responses and discussion for each scenario. So please feel free to share your comments in the chat box, but place your questions in the Q&A box. And Kari, who is on, will be helping us monitoring the boxes. Okay. So across line challenges, and we're going to go over the very first scenario. On our first scenario, we have a 20-year-old college student temporarily living in campus housing for the semester. They were sexually assaulted during a party at another dorm on campus. The assault was immediately reported to campus police. The following day, the student traveled back to their home state where they underwent a comprehensive medical forensic exam, including STI and pregnancy testing and prophylaxis. So thinking about this scenario, and please feel free to share your responses in the chat. When hearing this scenario, what are the initial challenges that you see? Would anyone like to share before I share my screen? And I'm sure we'll probably have overlapping challenges. So some of those challenges that you can see in this particular scenario is the coordination between the campus police and the healthcare providers and between the different states. So the coordination between them, ensuring timely access to comprehensive medical care is another one. And then which jurisdiction is responsible for picking up the kid? So that's another challenge that you have to decide. Would it be the campus police or the city police? And then what jurisdiction is responsible for submission for reimbursement? So to clarify a little bit on that one, which state or which jurisdiction will you as a healthcare provider submit your invoice to? So that's another challenge trying to figure out that one. And then which state would a patient be eligible for crime victims funds? So that's another challenge. And then a couple more that I can thought of and came up, but navigating the different state laws and policies regarding sexual assault response, handling evidence and maintaining the chain of custody across state lines, addressing the financial and procedural aspects of the medical forensic exam, managing the administrative burdens on the healthcare providers and the college and campus authority. Just one point. It is required to coordinate with healthcare across state lines if the police department has received the kid. The point for collaboration looks different depending on if the patient needs to report out or not. But it requires coordination for that to actually resolve and work out. So with the first scenario, when we look at the challenges, we're also going to talk about some of the solutions to those. And the ones that you see on the screen, those are like the main challenges that I'm thinking of coming up with this scenario. And I see a couple of comments in the chat. Yeah, so same comments before. So payment or challenges that I mentioned before, payment, evidence pickup, and then delaying care. Yes, going home to your home state does put a delay in the care. For our solutions, first, you want to contact the department where the patient filed the police report. For this particular scenario, this patient filed a report. And you want to reach out to that police department to determine if they will take responsibility or if they are responsible for the forensic hit. You want to consider the following. Does the campus police department have the capacity to perform sexual assault investigation? Depending on, and this could be in any college. In some colleges, their police departments may take on the investigation or they may turn it over to the city. But determining that would be reaching back out to the campus police in coordination with the providers who the patient initially had first contact. In the campuses, they are required to take the student's report due to the Title IX obligation. But did the patient consent to reporting to the city to police department? So those are other things you would have to consider and would only know or work through after you've reached out and collaborated with the police departments that are involved. To determine the source of reimbursement by identifying the agency that typically covers your regular in-state exams, your first point of contact would be to reach out to who regularly reimburses your program's exam. This will be your first point of contact to see if they will reimburse. But also note the following considerations with that, that some states will cover the cost of an exam for an assault that occurred out of state, provided that the state where the assault happened does not have a reimbursement program for medical forensic exams. So for an example, in Tennessee, payments for exams related to crimes occurring outside the state are not considered if the state where the crime occurred has a program that covers any part of the medical forensic exam. On this situation, if you were in Tennessee and you received a patient who came up or you performed a medical forensic exam for a patient where the assault occurred, you would reach right out to the Tennessee crimes and you would actually start your coordination with them and trying to find out if the other state has a program or not. But the first point of contact would be your own state, you would submit and go and work back from there. Tennessee, and we had a very similar TA that came up with this particular, in this particular scenario in Tennessee. And in that case, the same nurse or the program, they submitted to Tennessee and Tennessee had denied it. And they reached out to us. They didn't know why Tennessee denied it, but we had found out that they denied it because where the assault occurred, they had a whole program. And there was a process for the Tennessee nurse to have to go through for that to get resolved. And sometimes she didn't find that out until after she had reached out to us and we made some phone calls, but sometimes you may get a denial and they don't give you a reason why. And the only way to know, again, is to back out to them and asking that. And even reaching out to the state where the assault occurred to their crimes victims or their reimbursement program. And at the end of this webinar, we'll go over resources where all of this, where you'll be able to find that information and who to contact and who to reach out to. Any questions or comments before I move on? Okay, scenario number two. So this survivor, we have a 54-year-old Tennessee resident who was assaulted during a family visit in Washington, D.C. After returning to Tennessee the following day, the individual underwent a comprehensive medical forensic exam but decided against filing a police report. Consequently, the same program categorized the case as a whole, allowing the evidence to be stored for up to one year. The same program then submitted a claim to Tennessee for the cost of the exam since it took place there, but unfortunately this claim was denied. So before I move to the next question, after every scenario I'm going to ask the same question, what challenges do you guys see in this? And please share your thoughts in the chat box. I know in this scenario, when hearing this scenario, the initial challenges that we see, the denial of reimbursement by the Tennessee Department, the cross-jurisdictional coordination issues, variations in state laws and policies, victim support or continuity across the states, and again the administrative burdens on the same program, legal and the regulatory barriers, and then financial implications for the providers and the patients. And the biggest thing is patient access to support services. So again, the challenge or the question comes up, which CDC will reimburse patients for crimes in their jurisdictions? So I will say for most states, they will cover or reimburse for a patient for an assault or crime that occurred in their jurisdiction. Number one, again, reaching out to that state's CDC program, asking many questions about that process is always like the first thing you'd want to do for that one. I have one. So someone put into the chat, I'm having a similar issue with Michigan Health and Human Services and crime victims. Since we didn't use one of their kits, which we don't have access to, they are saying they will not pay. So yes, I have heard this before. I will say, I believe it's new, Hampshire also has the same process. They will pay for an assault that occurred in their state, but they require that the forms and the kits have to be there. Not so much the kits, I'm sorry, the forms. Not so much the kits, but the forms that you actually use to submit, they do require that you have them on their forms. And of course, the way you would find that out is if you had a patient from that state or from New Hampshire, and like I said, one of the first things you would actually do is reach out to that state's reimbursement agency to find the answers to their process. For example, in New Hampshire, I know if you reach out to them, they actually will send you the forms and everything that you would need from that department. So as soon as they get a request that there is an exam that occurred in another state or was assaulted in theirs, they will send you the information that you need to submit for the billing for that. Now, as far as with Michigan and with the whole different kits, I haven't heard that so much, and yeah, and that would be difficult without having access to their kits. But let me think about something on that before I respond further. And we'll go through, but there's some other answers and things that you can do that you can probably find those answers to that. And then with that one, that might be one of those ones where I said, there are some situations where they are almost the answer is really a legislative fix. And then she continued to say we have access forms for reimbursement online, but they say on the forms that they will not pay if we didn't use their kit. I'm going to touch base on that too, but there's also another little thing that we also have to keep in mind of what the federal law mandates. And sometimes the situations like this one, where you really have to figure it out. And I know it's like the federal mandate forces the states to coordinate and come up with a resolution to try and resolve that. For example, with even in Michigan, with this particular one, and they're saying, well, you have to use our kits, but the federal law, they have to pay for it. So it would be conversations with the funders of that department of the, of the reimbursement from Michigan, the reimbursement department that's covering those. It would be conversations with their people who are there and conversations with your own program in your hospital. And I know it sounds, but it really is like, you all would just actually have to come up with a plan for that. You can do it at case by case situation, but for that particular one, there has to be some form of resolution for them to actually cover and pay. Okay. So we'll go on. Okay. So again, as with any denial, you may know, starting with the agency that denied the claim is always helpful to understand your jurisdiction reimbursement process and requirements. Some states, like I said, will cover the cost of an exam for foreign assault that occurred outside of their borders. And Tennessee, as an example, will reimburse the claim provided the state where the assault took place, does not have a program or reimbursement program. Decision to cover the across state line exam will come on a case by case situation. For example, in Colorado where there is no standard or policy for across state payments. And the decision is actually made by one department and it's their safe program that reimburses the states that reimburses the states, non-reported and anonymous kids. And this would only be known by reaching out and having a conversation with that person. And what I mean is I say one department, but it's really only it's one person. And usually that person in that position I've spoken with across many states, the people who are in those departments, they are more than willing to actually help. And they're really more, a lot of them are more survivor focused. So in this particular situation, how I found this out with Colorado, I know we were actually contacted by a patient who had received the bill. And it was just me reaching out, finding out who that person was. And we have all of this on our safety TA website. We'll go over those, but reaching out to her and having a conversation and she pretty much just said, we make the decision on a case by case situation. We're talking with the providers in the different states. And she had even said at that point, almost all of the ones that come through and they didn't really get that many, but they made, she made it was the one that made the decision to go ahead and pay. And sometimes it's easier to do that because again, it's the federal statute that pretty much forces them to have to do that because the federal statute, and we'll go over that in this webinar a little bit later on, says that they have to pay. There's no other way around it. Going back to this scenario, in this scenario, the next line of contact would be the forensic nurse examiner program. And then following that, you would contact the victims of crime program or the other states victims of crime program. I'm sorry. Give me a moment. I think I've lost you. Okay. Yeah. So with this one for the solutions, you want to connect with the agency that reimburses your program's claim. And really that would, it should always be your first line, because like I said, they're also willing to help you kind of work through their process to find the solution. The agency that reimburses your program with, you know, reaching out to them, your state SANE coordinators. I found even through doing this program that state SANE coordinators, if your state has one, they are very knowledgeable about these processes and about what the federal laws and state mandates. And they're a good resource to reach out to them, to have you get connected to the right people and to find the right answers. And again, the state CDC, and then also your state advocacy services, if your state has those, they are also really good resources and helping getting your questions answered or getting these exams covered. Because again, they also know about the federal state mandates and they're always willing to work with you all because they, they again, are also survivor inpatient focused. Any questions or any other comments before we move on to the next scenario? On this scenario, we have a 25 year old patient who was sexually assaulted while visiting friends during a coastal vacation in one state. The next day, the patient traveled through a different state and decided to seek care at a rural hospital. There the patient underwent a comprehensive medical forensic exam through a forensic program that provides things to rural hospitals in the state. The patient chose to report anonymously and the kit was kept in hold status. The same nurse submitted a claim to the state of the medical forensic exam, but it was denied because the assault occurred in another state. And in this particular case, a little, some of it, I've changed a little bit of it, but it came out of Illinois, Iowa, across state. Sorry, my notes got all mixed up. But yeah, this particular case, it was, it was between Illinois and Iowa and it was an anonymous report. And what are the challenges here? And again, pretty much the same, you know, challenges, which jurisdiction is responsible for the kit across jurisdictional coordination issues. So you have the vacation state where the assault occurred, the exam state, and then the patient or the survivor didn't live in any of those states. So the challenge comes up, where will this patient receive reimbursement from crime victims? Which state? The variations again, in the state laws and the policies regarding sexual assault response and medical forensic examination, ensuring proper documentation of custody, the administrative burden, a lot of the same challenges, and then navigating again, the different states victim compensation programs. And again, that's another thing that changes. So there's different criteria for different states for their eligibility crisis. States will cover for a survivor or a patient that does not, is not a resident of that state, but the assault occurred there. And then you have almost most states. They do have a reporting requirement on, for when you're seeking CDC reimbursement for your, your patient, they do have reporting requirements. So I would definitely check know your state's requirements around that. They are different. I actually just found out what state was it, Iowa, no, Kansas. Now they removed that requirement. So for all of their domestic violence, IPV and sexual assault, they removed the reporting requirements. So just know which state your, your requirements are because they again are different. Any questions or any comments for any of those challenges? Okay. So with these again, so solutions for these, you're going to want to connect with the police department that takes the report or makes the referral, the agency that reimburses your claims to also find to find out the process want to identify jurisdictional responsibilities, again contacting the state or the agency where the assault occurred, contacting the state agency or the, where the exam was performed. So your state jurisdiction as well, even reaching out to their police department, where you are and where you regularly send your exams or which police department that your program regularly works with, speaking with them, contacting them about that process when you're trying to find out which state is responsible for the kid and the jurisdictions and things like that. If you have a relationship with your current police department or who you regularly report to or send kids to just reaching out to them and asking, you know, them about if you know who they can connect you with, or do they have any information when you're trying to, when you have an assault that occurred in a different state, they're the best ones to know that because outside of sexual assault or domestic violence, they would have issues where maybe they're looking at crimes that have occurred over the state line. So they would be the best ones to know about process and how to make contact with another state. When you're trying to find out the jurisdiction responsibility, and then you want to verify again, your state's reporting and reimbursement policies, especially when it comes to anonymous reporting versus a regular report. You want to review those policies in the state where you are and where the exam performed. You also want to facilitate interstate coordination. So again, like I was saying, establishing communication between your forensic program and the jurisdiction of where the assault occurred. And then another fix or another solution is advocating for changes to the legislative changes to the laws and the rules. So identifying gaps in your current legislation regarding cross-state cases, working with advocacy groups to propose those legislative amendments for better coverage. Because again, that goes back to when I was saying there are some cases where the only fixes is that we're looking at permanent fix would be those advocating for the changes in the legislation. And then you always want to document and track your process. You want to keep detailed records of all the communications and the attempts to secure the reimbursement. And this documentation, it helps support any future cases or any advocacy efforts for when you have to address this issue again. I'm going to pause for a minute. There are some comments. Someone says it would be great if there was federal legislation that would allow for evidence to be processed, regardless of the kit used. That's my business law. That's yeah, that's absolutely true. And then someone mentioned I've had my patient sign my form. Then I get the other state's form. I staple it together. That's a good idea. Someone asked if it works and it worked once. They took several calls to explain that I, she can't keep this day, but she said they have individually worked. And someone else said, yeah, the system is set up for failure. It is very challenging. I will say that. And then someone else said, I've had my patient sign my form. Then I get the other state's form. I staple it together. It's very challenging. I will say that. Okay. So scenario number four, we have a 16 year old patient who was sexually assaulted while on a domestic cruise vacation with family. The assault occurred on the ship while the ship was docked in a visiting state. The patient disclosed the assault and reported it to the cruise lines police department and received an initial triage assessment from the cruise lines, healthcare provider, where the patient was referred to a hospital that provided same services in a nearby state. The patient chose to disembark at the next stop and was transferred to the local hospital by the cruise line police department where the patient subsequently received a comprehensive medical forensic exam, including HIV prophylaxis, choosing to continue post-care at home. They also show to make an official report to the local police department who then facilitated the collaboration with the neighboring state police where the assault occurred. So this scenario is an example of what I mentioned before about reaching out to the local police department, your local police department in this case, and the patient wants to report, and you don't know which police department or who the first thing would be to just reach out to your police department so that they can help walk you through that process and who to reach out to. Again, what are the challenges we see here? And again, a lot of these challenges are a lot of the same. So you have the cross jurisdictional coordination issues. In this particular scenario, you have the vacation state where the assault occurred and you have the exam state. And then you also had the cruise line police department. That's almost like a different agency too, that you also have to coordinate issues with. And then again, which jurisdiction was responsible for the kid and then the variations in the state laws and policies regarding the sexual assault medical forensic exam process. So when we look at these, and again, the solution is like I said, mostly the same. You want to connect with the police department that takes the report or that makes the referral for the patient to come to you. The agency that reimburses your programs, your regular claims or your regular or your standard, I should say your standard claims for medical forensic exams that you perform in your state for those jurisdicts. You want to reach out to that agency as well, because like I said, they can help you through that process. Again, solutions include contacting the state agency police department where the assault occurred. If it is known to arrange for the kid picked up and jurisdictional establishment, as with this scenario, the patient chose to report. So if the police department information is known, they would be your first line of contact for any questions and steps moving forward from that point on. If the jurisdiction is not known, again, reaching out to your local police department, or your state sheriff's office for assistance with determining and making contact with the correct police department. And then also state SANE coordinators, your state CDC, and also the state where the assault occurred and any advocacy services that are available in your state. I have two more comments. And then the question is, who has jurisdiction if the assault happened on the cruise ship and it was not at a port? That's a good question. And actually our very last scenario coming up is international. With cruise lines and things, they're out in international seas and really, they're not in the international seas. They're out in the international seas, but they're not in the international seas. With cruise lines and things, they're out in international seas and really the first contact for that, again, would be reaching out to your local police department to tell you, or to learn how to navigate through that process in that jurisdiction. But cruise lines, it would be, that would be considered an international. Good question. Okay. So then that brings us to our scenario five. And that's the international one. So we have a 30 year old patient who was sexually assaulted while on vacation abroad. Upon returning to their home state in the United States, the survivor sought medical care and underwent a comprehensive medical forensic exam at a local hospital. The exam included collecting forensic evidence and providing necessary medical treatments, such as HIV prophylaxis. The survivor chose to report to the PD prior to coming to the exam. So who do I contact when the patient wants to make a report? Local police, state police, state department, or the FBI. But we'll look at those challenges. I guess I should ask, can anyone think of any challenges? I'm sure there's a whole bunch coming up with the international one, but any challenges that we haven't discussed before, does anyone see with this particular scenario? These challenges, again, the international cross-jurisdiction coordination issues, which jurisdiction will be responsible for the kit? You also have the variations in international laws and policies regarding sexual assault and the reimbursement process. And we have one comment. And the comment is, I had an international case where the rape occurred in Venice, and I did her exam in New York State. I used our New York State kit, and the FBI picked up the kit. New York State OVS reimbursed the hospital. Yes. And that is exactly what I was going to say. One of the first people you want to reach out to is your local police department, and then they actually will help you facilitate with reaching out to the FBI and who you need to reach out to for the international whole process part. But my point is, your local police departments, they are the best resource to find out that process when you're trying to identify jurisdictional responsibility and the whole process in which you need to go through that. Looking at international challenges, again, pretty much the same thing. The police department that took the report or your local one, the agency that reimburses your program's claims, the state SANE coordinator, your state CDC, and the state and your state advocacy services. And in this particular situation, connecting early with your CDC or state advocacy to help you navigate through that, because some states, and you would just have to know your state's jurisdictions, but some states, CDC, even though the assault didn't occur in the state, but internationally, if the survivor is a resident, they still could be eligible for reimbursement from the CDC. But you would only know that, again, by reaching out to them to help navigate through that challenge. Just a couple of, just a few, the next few slides, we're going to just go over challenges and solutions and, I'm sorry, solutions and how they relate to those challenges we just talked about when we're talking about what the federal law says. And that federal law is 34 U.S.C. 10449. We'll never use that term, but it's related to rape exam payment. What it says is that victims should have no out-of-pocket costs for medical forensic exams, and it should be free. So what free or out-of-pocket means is that the survivor is not covering any deductibles, they're not paying any out-of-pocket co-pays or anything like that. The state, the arrangement for these exams are to be absolutely free of charge for the victims. The law says that this should occur. However, this could look different based on jurisdictions. It should be noted that when speaking of challenges and solutions, that survivor status does not determine their access to the free exams. By survivor status, if they are an immigrant here, if they are a citizen or not, if they are an incarcerated survivor or not, their status, who they are as far as their relationship or license here, none of that determines their access to these exams and for them to be free. They're to be free for any survivor who comes in and requests for these medical forensic exams. And what this law says, it says that in spite of all of that, that states are required to cover the cost of these rape exam payments. The law does not limit state responsibility to only those exams for assaults that occur within their jurisdiction. Let me say that again. I know a lot of states have statutes that say they will only pay for medical forensic exams for assaults that occurred in their state. However, the law, the federal law does not, that statute is not in the limitation of the law. So the law does not limit that responsibility. What the law says is they have to pay. And pretty much what that means is they have to pay, so the states have to figure out how they're going to do it. And there are statutes that say they're only going to pay for assaults that occurred in their state. The federal law supersedes that. So determining which state is responsible for payment is complex. Some states deny a claim if the assault did not occur within their borders, or if the same that's providing the exam is not licensed in their state. However, some states offer specific guidance in their policies. For instance, Tennessee will cover a medical forensic exam, and I mentioned this earlier, if the state where the assault occurred lacks a reimbursement program. New Hampshire will pay for an exam if the assault occurred, that occurred in New Hampshire, if the exam was completed in another state, they will provide the claims are, they will provide the claims that they require for the exam to be submitted. And then in Colorado, while there is no specific policy or legislation for these cases, and I mentioned this previously, the Colorado State Program that funds their, that reimburses for their anonymous and non-reported exams, that's the agency that you would reach out to, and they cover for those exams anyway. When this agency receives a cross-state line exam, they consider the case individually. I had mentioned that before too, when deciding on the reimbursement or the state responsibility. So I do want to make a couple of notes in particular about insurance or the insurance reimbursement consideration. So part of the federal law that there are insurance reimbursement considerations. And so what that is, is that the issue with the insurance billing is that states can require insurance billing, and in most states, because CDC is the payer of last resort, that some states can require and submit for a patient's insurance. However, the considerations are, and the biggest one, if that state receives stop funds, which is a grant that pays for any portion of their medical forensic exams, they cannot have that requirement. Number one, they do not require insurance billing. It means that they can add, I'm sorry, they do not, with the stop funds, you do not, they're not required for insurance billing, which means that they can't add, but they actually have to do a true other option outside of insurance. So let me explain that a little bit better. If they want to use, if they're using stop funds, and if they want to use insurance billing, there's a few things they can't do with that. They can't require it, so they can't require the state to use or bill insurance first. And it means that if they do, they actually have another option to allow the survivor to say no. So if the survivor decides that she does not, or they do not want their insurance billed, there has to be another better option. And then the other thing is, if they decide that, it goes back to what I was saying previously about covering all of those costs. If they're using insurance, if the patient is being charged any deductibles, any copay, all of that would have to be covered and even spelled out in their policy for that if they're going to include the insurance billing. And another point to make, the exam, which is also part of this federal law, of course, has to be performed by a trained examiner for victims of sexual assault. It doesn't necessarily require a SANE, but the examiner does need to have some specialized sexual assault training. And then also, if they do opt for the insurance billing, again, like I said, either as a requirement or choice, again, they have to make sure that the patient is not being billed for any remaining costs. And they can't submit for any more than what the state will cover. For example, most states, they only cover a certain amount. And if you decide you're going to bill the insurance, it can't be like you can't, you can bill them. And if there's a lack in what the state is paying, you can't recover any more expenses out of that. So, instead, we're only going to pay, say, for example, they say we're only going to pay $1,000 for these types of exams. That's the only thing that you can't bill for them any extra, like when you bill the insurance, it can only be for the $1,000, it can't be for more than what the state already is covering for. I hope that kind of, I hope I made sense of that. Hold on, we have a couple of comments. Let's see. Okay. The question is, how do you all do it when a victim is brought to the ER and is an illegal immigrant who got assaulted in Mexico? Who is your authority to pick up the kid? Does same nurse send off to warehouse? And this person says, I'm from Texas and our local PD does not take the case as jurisdiction is not in the U.S. That is a good question. And I'll touch a little bit on that, but, and this is also a little plug, we actually have on August 6th, we are having a webinar directed specifically to immigrants in this issue that you're asking about. So, we'll have the output, the information for registration for that in the link. But in this particular case, we are, and I know Texas, as you were saying, they won't even take the case or anything like that. But with international, if you're not getting help from your local jurisdiction and they're saying flat out, we're not going to do it, then the next thing would be state sheriff and then FBI in your jurisdiction. And then there's nothing wrong with even asking that if they say, letting them know we have this here or we're not going to cover it, we can't do it. Can you help me reach out to who I would need to talk to in the FBI who would help cover this? Because it is an international cross state. And again, the only other thing I'll say about immigrants that I can confidently say now is that again, the patient status, who they are, citizen or not, has no jurisdiction on the state themselves where responsibility. So, an international law and looking at what the law says that states have to pay for these exams, it doesn't matter if it happens internationally or if it happens across state lines. That state that performed that exam has to cover that exam and they have to have a process to cover it or options to help you cover it. And so, when I say, when I go back to the federal law, I say my biggest thing is lean on that statute to pretty much force them to help you figure that out. And it's really not forcing them because the other thing I found, a lot of people who work in this field, the departments and things and stuff like that, they really are willing to help you and help figure it out because a lot of them I found are really working for their own survivors. I hope that helps a little bit. One more little point on this slide, I'm sorry, I'm sorry, I got mixed up on my side of it. Again, like I was saying, for this, the law states that the exams are provided at no cost. Arrangements of these exams are to be free. There are insurance reimbursement considerations that we talked about. And no criminal justice participation is required. I have one other comment. The last comment about the Texas and Mexico, I want you to comment, yes, thank you, that we ended up doing the same exam and sending to warehouse for storage, but we'll reach out to the FBI. Looking forward to that seminar as we get our broader town. Okay, yes. We'll make sure we have that, the link to the registration for that one for you. Okay. And then going on again with the federal law, statutory requirements. So survivor status, again, does not determine access to these exams. States must cover the cost per the law. Jurisdictional complexity, the law does not limit state responsibility to assaults within their own jurisdiction. And then the biggest thing I can say is just know your state reimbursement requirements and more to come on those resources at the end of the year. Okay, so more challenges and solutions, and this is just talking about the legislative solutions that I was saying, and really it's, we're advocates too for our patients advocating for these changes, identifying the gaps in the current legislation regarding these prostate assault cases and working with local advocacy groups to propose these amendments and for better coverage and medical forensic exams for these types of assaults. And another good resource is if your state is a state, and I will say almost all states are receiving STOP grant funds in some form, but you would need to know how your state is actually using these funds. But the administrators of these funds in those states, they are very helpful in working with states and getting these exams paid and covered because they have restrictions and requirements that they have to follow for a state to even get these funds. They have a vested interest in complying with the STOP requirements. And again, federal law requires the coordination. Lean, I say this all the time, just lean on that statute, the law. We're talking about tools and resources. So this here is on our website, safeTA.gov, and it's a state-by-state billing resource map. When you log on to safeTA.org from the homepage, you'll see a tab that says exam payment. And when you click on that, it'll bring you to a dropdown and you'll go to payment resources. And payment resources takes you to this map and it is interactive. And you click on the state that you're looking for the resources. This page, it houses a summary of the billing and payment information for every state, territory, and district of Columbia, military, and Canada. These pages also include various links to coordination with health care, and they include external links for the states or locations that have kit tracking databases. For some of the state locations, there are also either external links or downloadable PDF versions of their claim reimbursement forms. So in those states where they're saying, hey, we'll pay, but you got to put it on our form, you could actually come here and you can link to that state and you'll be able, if the state hasn't provided online, you'll be able to get connected and get those forms from this. And for almost all of the states on this map here, there's a link to their state crimes compensation, to the department, the contact person who you would need to reach out to. And we also have the applications and brochures for your patients as well. So this is like my number one resource that I can go to when we get questions regarding on a specific state. Now, I will say, and I know in some states, it gets even more, it goes down even more specific because it goes down by county. And in some states, even the county is different. We may not have the specific county, if your state is a county by county payer, but we'll, it'll be stated in there, and then you'll get the information and contact to your state who can give you more information and further accounting. We have another comment. Oh, Carrie just put up the, she put the link in the chat to the resource. Do we have any questions before I go on? We're going to finish it up with more resources. There are no questions currently in the Q&A, but anyone who has one can go ahead and enter it, or since the chat is so active, we can also read it from there. So this is also from our exam payment website page on SafeTA. And when you go to the homepage and you just click on the exam payment bar, it'll take you to this, to this page. And here you'll see each box that you see there, each square has, there's a different range of accessible resources. So the first box that you see there are payment fact sheets. We have fact sheets that cover ICD codes, CPT codes. We have fact sheets that cover, what do you do with a patient gets a bill? And it's the fact sheet actually says that, what do I do if my patient gets a bill? And then a couple of fact sheets that are actually going to be putting on, or that they're going to be on the site within the next month. We have one that we're going to put on after we have the immigration one, but it's going to be, we have another one coming out, which is going to address issues and getting exams paid for incarcerated survivors. And then we'll have, and this one will be out probably in the fall, but one addressing military, those in the military and military survivors. We also have some payment research, exam payment news, and the payment resources map, payment tools, and we have also webcasts. And those webcasts, we have webcasts that show or explain and show how to fill out billing forms. And it takes you through that process, explaining ICD codes. So if you have questions about medical forensic exam coding and ICD coding, we have all of the information regarding those codes as it relates to medical forensic exams. We have webcasts about them, and then we also have them in the fact sheet. I have another comment. Oh, that's Terri putting up those links for you guys in the resource. So this is at the end, and I'm going to open this up for any questions or comments or discussions about what we just talked about or any of the resources, or if you had any questions, if you'd like to ask. It doesn't seem like anyone. When I answered all your questions, then that makes me feel happy. For any additional resources, in conclusion, we would like you to visit forensicnurses.org or safetya.org. We also started this year a new way where you can access the forensic nurses here if you have any questions. So on our forensicnurses.org site, we now have a Ask a Nurse click button. So if you have any questions regarding your practice, in particular, any billing questions, you can go to forensicnurses.org and hit on the Ask a Nurse button and ask your question, and a forensic nurse specialist will respond back with your answer. And we usually make those responses within 24 hours. We also, we still have the TA line, so that's the technical assistance helpline. If you have any questions regarding your practice, you can call that line there, or you can even email us at safetya.forensicnurses.org. And again, those payment pages and resources are all on safetya.org. I really encourage you all when you get a chance to just take a look at the resources that are available, even if you're not going to use them right now, but get yourself familiar with it. And then so you know where to go to when you do have a question. Everyone is saying thank you. And if there are any more questions, thank you again. The references for this, again, are also on our safetya.org webpage, the U.S. Department of Justice and the National Institute of Justice references. I'd just like to thank everyone for coming and joining this webinar. I see they have put the evaluation link into the chat. So please, for your continuing education, we ask that you fill out the evaluation link. And again, thank you so much.

medical forensic exams

reimbursement

cross-jurisdictional

survivor recovery

state laws

sexual assault

federal mandate

legislative changes

billing resource

technical assistance