Strategies for Resolving Medical Forensic Exam Payments with Survivors. So just a couple of housekeeping, and just wanted to let you know of some acknowledgments and disclosures. This webinar has received support through a grant from the Office on Violence Against Women, a part of the US Department of Justice. It's important to note that the opinions, findings, conclusions, and recommendations shared in this presentation are those of the authors and may not necessarily represent the views of the US Department of Justice. A special thank goes out to OVW for making today's presentation possible. This session's planners, presenters, and content reviewers have no relevant financial relationships and ineligible companies to disclose. And to receive a certificate documenting the contact hours for this webinar, you must evaluate it and complete the evaluation at the end. And Mary Kate will give us information, and you'll receive that link to do those at the end of the webinar. The International Association of Forensic Nurses is an accredited provider for nursing continuing professional development by the American Nurses Credentialing Centers Commission on Accreditation. And getting to us and the presenters today, so I'm Coren Grzelik, and I'm a forensic nursing specialist at the International Association of Forensic Nursing. And in my role here, I offer training and technical assistance covering a range of topics related to the national safe protocols, the national IPV protocols, national training standards, and issues related to payment for medical forensic examinations. Today, I'll be co-presenting with Sarah Gold, who is the attorney advisor with the Office on Violence Against Women. And I'm going to introduce her now. And I want to tell her thank you for joining us in this webinar. It's much appreciated for her expertise and knowledge that she's going to bring to us. And I will turn it over to her for her introduction. Hi, everyone. I'll be brief. As Coren said, my name is Sarah Gold. I'm with the Office of Violence Against Women at DOJ. I come to this job with 20 years experience as a sex crimes prosecutor, both state and federally. So that's what I can add today. And I will add what I can about the rape exam payments. But mostly, this is Coren's show. So I'll be happy to take your questions and add where I can. Thank you. So by the end of this webinar, you can expect a deeper understanding of the importance of the medical forensic exam and survivor health and healing. You'll be able to identify common pitfalls and challenges faced by survivors related to medical forensic exam billing, explore strategies to assist survivors in resolving billing issues and navigating the process effectively, and also develop skills to support survivors and build effective resolution strategies. Our purpose statement for this webinar, as you all know, is dedicated to sexual assault responders, health care clinicians, service providers, advocates, and nurses. We are often the first point of contact for survivors facing unexpected medical forensic exam related billing issues. And upholding a victim-centered and trauma-informed approach, we must ensure that our survivors' 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 they're also for the criminal justice process. And it is our responsibility to be well-equipped with knowledge and strategies that are necessary to guide our survivors through these financial and difficult challenges. So I'm going to start our discussion off with our first discussion question. And you can put your responses in the chat. And we'll look at it a little bit. But this is just to get you guys thinking and start some discussions. And then we'll talk more about it as we go through. But I'd just like to know, considering the billing and medical forensic exams, what have you experienced currently in your field when it's related to survivors and issues of getting these exams reimbursed or issues of survivors receiving bills? And we'll wait for a couple of responses. Oh, yeah, so someone, good point. Someone put in that some homeless patients or survivors are unable to pay for meds up front at discharge if they're inpatient. Yeah, someone else also mentioned that they're noticing that some victims are also being charged the facility and physician fees. We are seeing those, too, as well. And then someone put in issues related to, oh, you guys are really responding. I'm liking this. It's jumping a little. Issues related. So issues related to paying for medications that require a prescription and also tests that are not covered by the forensic exam requirement. This is also another one we'll touch on. Oh, someone mentioned a really good one across state lines. It's a hot potato, and we'll also discuss, talk about some upcoming webinars, but we actually have one coming up that's going to address that issue. But yeah, that's a big issue, too. And then someone else put intimate partner violence-specific exams instead of paying for the same exams. That's another sticky one, too. And we'll talk in a little bit about that one as well. So prescriptions, yeah, paying for prescriptions, co-pays. We're seeing a lot of those. And then also trouble paying for NPEPs and the HIV. So wow. So those were some really good responses. A lot of what I kind of expected to hear, I kind of wanted to see, you know, I hear things that are happening on a broader scale, but I always like to know what's happening like right, you know, right on the ground and what you guys are experiencing as well. So thank you for sharing those experiences. And we're going to talk more through as the webinar goes. So as you know, we all are aware of these challenges surrounding payment and reimbursement for these medical forensic exams. And it's concerning that these patients receive bills or paying issues related to those services. And especially considering the efforts, it's really concerning, especially considering the efforts that are put in place to kind of prevent those occurrences. There's resources and even the way that the systems are designed. But today, we're here to address that and address it with advocates, service providers, and healthcare clinicians who are directly impacted by these issues and seeking solutions to ensure that our patients are not burdened by the financial concern in the aftermath of a traumatic experience like sexual assault. All of those are important for us to discuss and we'll go over them as we go on. Okay, so this next slide, so we're going to start talking about VAWA and this is going to be a great opportunity for me to share my screen. I'm going to send this over to Farrah, our co-presenter, and she's going to talk to you guys a little bit about the background on that and as it relates to the Violence Against Women Act. Thanks. I was going to, you know, start off by saying this about what is required. I feel like most of you know this and the problems that are arising are kind of like in addition to. So let me just first start by saying that a lot of the issues that you're raising, you'll see my email at the end. I'm happy for you to email them to me in terms of as, you know, VAWA gets reauthorized, hopefully every five years and there are some fixes that we're looking for. So I encourage you to email me, you know, I don't know that I could solve it immediately, but we have a running list of what we want to try to fix. And I'm happy to consider those and work with you on that. But as you probably all know, in order to receive STOP federal funds, which is a formula grant that all the states and territories are eligible for, they have to certify that they are complying with the rape exam payment statute. So what does that mean? That means, and that's what it's called, rape exam. So I'm not, I just want you to know that they are the statute, not what I call it. So that means that sexual assault forensic exams are covered by the state, that patients, victims do not bear the cost of it. And that government entities have to work with all VA and health care providers to notify the community, your communities, of the availability of free sexual assault forensic exams. Go to the next slide. And so this is the statute. This is why I called it rape exams. It's 34 U.S.C. section 10449. You obviously don't need to know that, but basically in order for the states to get this money, they have to certify that these exams are free and that the arrangement of the exams are free to victims. Right? So that there's no barriers of access and that there's no reimbursement requirement for insurance and no criminal justice participation requirements. So there's no condition on it. So the idea that these exams are free to survivors and victims, to your patients, and in order for these states, for all 56 states and territories to get this money, they have to certify that they are complying with this. And we know, based upon your comments, that it doesn't cover everything, but it certainly covers the forensic exam piece of it and the medical treatment that comes directly from that. So it doesn't cover everything, which I know is an issue. But this is a floor. And so if we could go to the next slide, yeah, that a lot of the states' territories go beyond that. Right? And so that's the idea. And so if you go to safety.org, there's a state-specific map of protocols on what is covered. So the floor is evidence collection and related medical treatment, but some of those states go beyond that. You know that based upon your own experiences. So I always would encourage other states to go beyond what is the bare minimum, and hopefully at some point, we can get the statute to cover more. And so the bare minimum is raised a little bit more. Okay. Okay. And so building on what Farrah started with Val, well, we're going to, over the next couple of slides, I'll provide an overview of the Victims of Crime Act, or VOCA, and how that also relates to our conversation. So the Victims of Crime Act was passed in 1984, and it established the Crime Victims Fund. And it uses non-taxpayer money for programs that service serving victims of crime. A notable effort is the formation of the Crime Victims Assistance Programs that are within states, and it's primarily funded by the state's Crime Victims Fund, which often covers expenses for medical forensic exams or services provided as it relates to or related to the medical forensic exam. VOCA is the most common source of funding for medical forensic exams, with about 80% of states using it to cover the cost of all, or at least some of the exams, and 67% using it to cover the cost of all exams conducted in their state. There's also other sources that include law enforcement funding, and I'll give a good example of that is Colorado. So their local law enforcement jurisdictions are the ones that cover those, and it does come from a separate fund, but just so you can get an idea of that, public health funding is also used, and then you have the county-administered models. Approximately about 40% of the states use the county-administered models. So VOCA establishes two primary funding mechanisms. They provide assistance for victims and compensating for their expenses, and they also provide victim assistance funds, which are allocated to service providers to support survivors directly, encompassing aid for various violent crimes, specifically in our situation, including sexual assault exams. The compensation stream directly reimburses victims for their incurred costs via state-administered crime victim compensation programs, and then these victim compensation programs, they're pivotal in covering personal expenses for survivors related to sexual assault incidences. So a good example of that would be, so if they needed like aftercare or post-care or post-medications or prescriptions that was not covered in their initial exam or the initial assessment, those are things that could be billable or reimbursed through victims' compensation straight directly to the patient or the survivor. So that now brings us to our first question, and you can place your answers in the chat. So based on what we just talked about, whose responsibility is medical forensic compliance? And that would be either A, federal state agencies, B, SANE nurses, C, billing department, or D, the patient or survivor. So it looks like we got over, a little over half who've responded, or 65%, and most of you, if you were correct, if you said A, the federal and state agencies, and that's just in a review of what Farrah had mentioned about states and their responsibility with compliance. So real good. You guys got that one all correct. I did see a hand raised. I don't know if it was for a separate question. Let me, I think it was Lisa asked the question. I don't know if it was with the same question or if she had another question to ask. Lisa, you can't, I'm going to let you be able to unmute yourself. So you should be able to unmute yourself and let us know why your hand's up. Okay. I think we can probably move on. Okay. All right. So, okay. So, like I said, you guys did really good with that one. So, going to our next slide. So, we're going to talk about payment models and variances, which definitely varies state by state. So, the map that you, that we're looking at now, so this map was developed in an exam payment brief, which was produced by the Urban Institute in partnership with the International Association of Forensic Nursing. And on this slide, you see a map of the U.S. It's color-coded by state and their payment practices. Each color represents a different payment practice or payer, and it represents VOCA for Victims of Crime Act, VAWA or the Violence Against Women Act, county-level sources, and public health state payers. You also see a variety of payment practices across all the states. Some states receive exam payment and reimbursement through VOCA funds, as we mentioned before, a combination of VOCA and VAWA funds, through law enforcement, and then a combination of law enforcement and VOCA, and then always, and some always, through the county where the assault actually occurred. And then through public health state payers, a state's funding and reimbursement model pretty much boils down to and depends on the state and its resources that it has. But this map is a solid representation of how much that variation goes into the exam reimbursement. You definitely can check your state's billing process through safetya.org. I'll go to that next slide right away. So this is actually a screenshot of what the site looks like on safetya.org. It's a resource map, and it's under the exam payment tab, which when you go onto the website and you go into payment resources, it will take you to this map. And this page houses a summary of the billing and payment information for every state, territory, the District of Columbia, the military, and Canada. These pages also include various links to coordination with health care and include external links for states or locations that have a kit tracking database system. For some of the state locations, though, there are also external links and or downloadable PDF versions of their exam reimbursement claim forms. For almost all of the states, there is a link to the state crime victims compensation and their applications and brochures that you can also access for your patients. But definitely, this is probably a number one go-to resource for you all to have as your back pocket if you have any questions or anything related to what your jurisdiction or what your state offers and provides. And so I'm going to start. We're going to talk about just the philosophy aspects of MPAC, and I'm going to let Farrah start hers with the justice impact. Thanks, Corinne. I feel like this is, you know, we all know why we don't want victims to pay, right? Because we want them to report. We want them to find, more importantly, get medical care. And so that's the whole idea behind this, right? If a house is burglarized or there's a home invasion robbery, you know, police come and they collect evidence and we don't charge the victims for getting their house, for getting, you know, the crime scene, so for evidence. And it's the same idea here, right? If we want victims to report and we want them to get the treatment they want and we want to break down the barriers. So that's the entire idea behind paying for the forensic exams, that a victim shouldn't incur the cost of victimization, that they shouldn't incur the cost of evidence collection, and that we want to break down the barriers. Based upon everything in the chat, we know that there are barriers, not only to reporting, but to make sure they don't pay for it. So the first step to break down the reporting, the barriers to reporting, is to make it easier to report. And one way to do that is if they don't incur costs, because there's so many other kinds of costs incurred as a result of victimization. This is one way to make it easier to report. Yeah, thank you, Farah, for that. And just to build on that and that philosophy and on the healthcare side of it, and specifically the forensic nursing care portion of that, you know, forensic nursing care is founded upon theories and models referenced in the nursing care model. And it's to provide specialized and equitable physical, mental, and emotional healthcare to patients impacted by violent natural disasters or mass destruction. And that is from the ANA and IACN statements. Forensic nursing care is patient-centered. It's trauma-informed, reflecting best practices for developing evidence-based practice. And best practices are determined by employing nursing critical thinking skills and the nursing process that we all know with nursing to individualize that patient care. Forensic nursing care includes assessing, evaluating, documenting, and meeting trauma responses and injuries. Furthermore, forensic nursing care supports violence prevention through education and legislation and policy reforms. Oh, I'm behind a slide, but again, community-focused healthcare philosophy, community-focused, we support violence prevention and the education and philosophy. So, now in this portion of the webinar, I'll go over, well, I will be going over four case scenarios. We'll walk you through the decision tree for what do I do if a survivor receives a bill? These scenarios, I've gathered these scenarios from cases that I've provided guidance in TA when a survivor actually made direct contact with me. The scenarios are very basic, but while we go through these scenarios, please feel free to place questions or comments in the chat box. Well, really questions in the Q&A, comments and things like that in the chat box, and then you can always use the raise your hand if you wanted to speak on that. So, let's go to the next slide. So, there's four scenarios we're going to start with. There's three that were actual TAs, and there was one that I imagined, and so that was really this first one. And the description of that is where a survivor receives a bill from the hospital for the full entire medical forensic exam. And I'm meaning medications assessment, including the kit. Now, I have myself not experienced this or knowing that a patient's received a kit, but I can only imagine that I'm sure this scenario may have presented somewhere in this world of ours. So, we have a 42-year-old uninsured patient who arrived at a small rural hospital's emergency room seeking a medical forensic exam following a sexual assault where there was no SANE on the staff, so there was no SANE available at all. And the ER physician and the bedside nurse conducted the exam. They collected evidence for the rape kit, and they collected basic labs for urinalysis, and they provided STI and pregnancy prophylaxis. However, the patient was not provided with any referrals for post-assault care or victim support services, and the patient also chose not to report the incident to law enforcement. Three weeks later, the patient received a bill for the emergency services, the lab work, the cost of medications, and including the evidence collection. So, looking at this scenario description, and this would be the first poll questions related to the scenarios, where would you start to solve this scenario? Would you start with the first place that you start, be with the facility billing and coding department, the facility's social workers, or would you start with the clinician or the provider providing direct services? And you can actually just write in, because I didn't do, I don't think we did A, B, C, or D, just write in your answer. But please respond and explain kind of like why you chose that one, like why would you start there? And I know there's probably, if there's going to be a lot, we'll go over a few of those responses. And we'll look at some of these responses. So, we have some who've answered facility coding and billing department, the facility billing, social worker to help connect with victims, comp, yes, billing and coding department, billing and coding department, yes. So, those are all good responses. And the answer is actually, you would first reach out to the facility that provided the direct services. And so, we'll go over that a little bit more, but this imagined scenario, it points on survivors receiving, and just a little note, receiving bills for rape kit collection. And I want to just make a distinction between actually rape kit collection and versus the medical exam and the distinction between the two, for example, and I can use Texas, for example. So, Texas actually separates the medical forensic portion, which is the actual evidence collection. So, it's why the actual kit from all of the other medical stuff, so from like medications, prophylaxis, and things like that, and it's two separate processes. And so, in this particular scenario, what I was really trying to let you all see is that with a patient or a survivor getting a bill for evidence collection is something that we have not seen, but that's what we're talking about, the actual kit part. And so, the reason I wanted to make a distinction on that is because I haven't seen this, and I hope it's not going, but most places, they know that the actual kit portion, the billing is separate, and it goes straight to wherever who's going to bill that. And so, we usually generally don't see a patient who will get charged for the actual kit, and even that process is different throughout the states. So, for example, I want to say Georgia, they have a whole separate funding for their actual kits, and it's under through their CSI and lab process. So, it's a whole different thing. But just to make the distinction between that, so as far as if you need to know that, so if a patient comes in, survivor, and they have an itemized bill, and it says like evidence collection, and it's, you know, if they're being charged for that, I believe that one is a little bit more serious if it's looking like they were charged for the actual kit, and getting more advocates or providers involved, because we know that should never, like, they should never get charged for the actual kit. And I don't know if Farrah can back up on me on that one, but that should be like, yeah, that would make me really mad to know that they actually got, you know, charged for the kit. But anyway, let's move on. But in this situation, like I said, I would have first reached out to the facility. And if this is a facility that doesn't have a SANE, they don't have those services, they may not have been aware that they couldn't, you know, reached or couldn't send that bill. And so, the first thing would be to reach out to them is to, one, find out if it was the, how their department, so it may be, if who's processing their bills, I'm sorry, if it's the emergency department, or if they're using their billing and facility department. So, making a determination as to who actually sent the bill, you will want to reach right out first with to the emergency department and to the providers to find out where, who does that. And then that would be the next person you would reach out to. And then making a connection with this, with the hospital and the state's crime victims program, or if this was in your state, if you knew or finding out where those bills are getting, are getting sent. I'm going to look and see if there's any questions, right? There is one question. So, the one question we have, someone's asking, when law enforcement pays directly, do they typically have designated funding that they receive federally, or how does that work? So, good question. And that question also looks different everywhere. So, that really depends on the law enforcement jurisdiction. Some may have funds designated specifically, and some, you know, may not. It all, it really does all resolve, you know, around the actual jurisdiction. And that would be a good question and a specific question to ask in your specific area. So, for say, if you know law enforcement pays, then reaching out to them and asking those questions like, okay, how do you know, how's your funding work and things like that. But to be aware that sometimes it can happen is also good. And then, okay, so Farrah's going to also answer this question. Go ahead, Farrah. Oh, no, you had it correctly. I mean, sometimes the stop funds, I just wanted to clear it out so it didn't stay there. But you had it, you had it correct. It does vary. But that's one of the things, one of the use for stop funds as well. Yeah. She just, I just got a question about the poll. So, yeah, we'll do that. Okay, so I'm gonna see if there's any other question. Okay, so no other questions. So, we'll move on to the, or any other comments in this, for this particular thing. Oh, I'm sorry, she put the poll up. These are on poll questions. So, I know you all responded in the chat, but we can, if you all just right quick, just redo your answers and then we'll move on to the next one. Okay, so you can launch this one soon after I describe the scenario. All right, so this, this next scenario, so then actually the next one that we're going to go through, these are all scenarios where I provided TA and was contacted directly from a survivor. So, this one is going to describe services billed outside of the exam, where the survivor receives a bill for the emergency room visit and an ambulance transportation. So, a 30-year-old patient who is insured under Medicaid sought a medical forensic exam for a sexual assault at a small community hospital's emergency room. The hospital, lacking SANE services, has an agreement with a nearby university hospital to transfer such patients to their SANE program. Upon arrival at the first hospital, the patient underwent initial triage and a physician's assessment. They were then transported via ambulance to the university hospital, where they received a full medical forensic exam, including evidence collection and tests and treatments for STIs, pregnancy, and HIV. This comprehensive care at the university hospital was provided at no cost to the patient. However, two weeks after the assault, the patient received a bill from the community hospital for the initial emergency room visit, the physician fees, and the ambulance transfer, totaling more than $4,000 for this patient. So, our next question, you can go ahead and put the poll up now, Mary Kate, thank you. So, our next poll question is, with this scenario, where would you start? And again, you can actually just put your explanation, I forgot how we were going to have you set up, of why, if you want, in the chat box. And then we'll discuss those. Just waiting for a few more responses. Okay, we got almost half answered and mostly everyone answered correctly, 57% said the state CBC. So in this scenario, I did just that, I contacted the state CBC. And I initially was thinking that this would be direct survivor reimbursement for the related medical forensic exam services because, you know, remember I mentioned before, sometimes for services outside of the medical forensic exam and sometimes that can include ambulances and if they were seen, you know, prior, did a transfer. And I kind of figured this would be one of those. So I contacted the state CBC. And this did happen in Maryland, I believe, yes, Maryland. And I contacted the state CBC first. And like I said, initially, I thought it would be, you know, me connecting them with them to start that process to get her reimbursement. But however, through this contact with CBC, in this particular state, the hospital that performed the initial assessment was eligible to receive reimbursement for those services that the patient subsequently was billed. However, what had happened was the providers in this particular hospital that sent, they were unaware that they could have sent the bill to the state CBC program. So in this case, contact was made with the sending facilities, billing department after, through the CBC and resources and education on the CBC billing process for these particular type of patients was explained to them, not by me, this particular person who I contacted at the CBC in this state was just overwhelmingly helpful and kind of facilitated the whole process. And she was able to work with that facility and the survivor to resolve and get those services, those charges reversed with her through her insurance. And then just to talk about even the other options, it would not have been a good, you know, a bad idea to contact either Medicaid or Medicare. So another way how I can kind of tweak this scenario, in some states, they allow for facilities and programs to also bill a patient's insurance for services that are not related. However, that's a sticky one. And we have a scenario kind of similar to this, they have to get the patient's consent. And the patient has to agree. And the patient has to be made aware of what their insurance covers and all of that before you can, you know, say, well, we're just going to charge your insurance. It has to be given a choice for the survivor and the patient. And then also in some cases, I believe Medicare and Medicaid will cover some of those. And again, like I said, that's going to be specific to the state. Because of the Medicaid expansion and things, some of the benefits are state specific. So that would also be reaching out. So the other two, and even private insurance, like I said, if they had insurance, they wouldn't be, you know, bad options to choose if they, if that was the case, and if it was a case where the state was allowed to bill their insurance and reaching out to them first. So, and then we're going to look at any questions right quick. Okay, give me one second. I'm just reading a couple of questions. Okay, so someone commented that their crime victims is payer of last resort. So we would have to go through Medicaid first. Yes, some of those are. That is the case. Yes. So in this situation, if this was a state, you know, is that and that insurance, it wouldn't be a bad idea to contact the insurance first or the Medicaid. So I have one other question. So someone's asked, so based on this scenario, it sounds like hospitals are allowed to send a survivor to another facility for a forensic exam. I had a discussion with an advocate who researched and was saying that a hospital was not allowed to send the survivor elsewhere, that they have to provide the exam there. And you're absolutely correct in that. So one of the things in the scenario I mentioned was that the hospitals had a contract to be able to send those patients to them. So in that incident, so there has to be a contract in place. There has to be a policy and process of how our hospitals want to take care of these this particular patient population and if it's decided because we don't have the services or we can't provide them as in any other like healthcare situation. So for instance, a patient who presents at a hospital for a heart attack and needs a cath lab, and that hospital doesn't provide it, they probably have an agreement with the another hospital to provide that service. So it's pretty much the same, as long as there is an agreement in place. Yes, a hospital, if a patient presents to a hospital and they don't provide those services, they can't just send that patient to another hospital that they know takes care of these this patient population. No, it has to be a process of policy in place before that they are allowed to do that. And in this particular scenario, there was an agreement in place. It just I think the sending facility, because if I can remember, it might have been a fairly new and, you know, maybe the emergency or the healthcare providers who worked with that patient at that time wasn't too aware of that process. So that was a lot about education too in the policy. Okay, did that answer the question? Okay. Okay. And then we have good, I see the thumbs up. So then we have one other question. I'm just curious, some places are not yet doing follow up calls yet, or case management reaches out. Is that how this played out? Was this info obtained during follow up call? And did the patient reach out? No. All of these cases here were directly IAFN in our contact information, we were directly contacted by the patients themselves. And I will say in all the cases, it was all they didn't contact that it was only the reason they contacted us because they had did a little research on their on themselves. And they knew that something didn't feel right by why they were getting charged, like, almost of the survivors who I've been, you know, contacted by, they know that they should not be charged for these services. So, and they, you know, with the internet and everything, they get to doing a little bit of research, and they usually end up landing up on our resources. And they reach out like, hey, this happened, I don't think this was supposed to happen. So that's how it's come to me. I've never been contacted or reached out through case management or an advocate or anything like that. Okay, so, so now we'll move on to, to the next one. So, the next scenario is where, and this is another kind of insurance one, but it's when the insurance was billed without the survivor's consent, and the survivor receives the exclamation of benefits. So, the scenario goes like this, a 24-year-old college student saw a medical forensic exam at a local college's SANE program following a sexual assault. The student received a comprehensive medical forensic exam, including evidence collection, pregnancy and STI prophylaxis, and HIV testing, and they also received medications accordingly. They were then directed to the college clinic for continued post-assault care and counseling services, which the student utilized. A month after the assault, the student received an itemized explanation of benefits detailing the charges that were covered by their insurance for medications and lab services at the initial visit. Although offered the choice to bill their insurance, the student chose to have the costs covered by the state's Victims' Compensation Program and the campus program funding, which also covered all of her post-assault care services, and in which her insurance was not billed for those. So, looking at this one, where would you start to solve this? The insurance payer, the facility program, or the state CDC? Yeah, it's not even 40%, and they're almost all correct. Yeah, so 69% of you all say have the correct answer, facility program and the billing department. Okay. So, yeah. So, in this scenario, I was actually contacted by the survivor's parents, who were the ones who actually received the ELB, but the assault was known to them, and they were very heavily involved in the survivor's healing process, and it was the mother who actually got her connected with the free services through campus, and so the mother knew already that they should not have gotten a bill, and they were asked, and they denied for that to happen. And so, and she just kind of, and she reached out, because she, the mom, she just wanted clarification, because she's like, she understood that all of the services would have been covered by the campus program and victim services, and she knew she consented for them not to bill, but she was just kind of wanting to make sure that she hadn't missed anything. And so, in this case, I immediately just, we reached out to the campus program, where the initial exam occurred, and the survivor, through, we referred them, we spoke with the program facility, and the good thing was, because the survivor was already connected with advocacy services, we were able to connect her back with her advocate, and then they were able to come together to resolve the issues with the insurance company, and reversing the insurance charges, and going on with the process for the CBC and the campus program to reimburse them. So, this actually happened, so it was a little, it wasn't across state lines, however, the patient was not, the survivor, this happened in Arizona, but the survivor was from Texas, and she was a resident of Texas, and even the insurance was out of Texas, but to be honest with you, even all of those differences, it really didn't matter what Arizona did, and what their obligation was for her, so sometimes you may get tripped up with that if you get, you know, reached out for someone, and the patient may live somewhere else, as opposed to where they had the exam, don't let that trip you up, just always refer back to the point of where the exam was taken, and then going through those, that'll help you sort that out, so it really, it really was an issue, but this happened in Arizona, and I can't really remember what the, which campus it happened at, but it all ended up working out, and this was like an afternoon fix, and what had happened was the program, it was literally a glitch in an oversight, so it was also educating the healthcare staff, because it's little things like that, that we as providers, especially the healthcare providers at the bed who are involved with filling out the invoices, just making sure that documenting like consent, and then documenting that it's going through with, through the processes or, that have to happen, so if the next point of contact, you know, the billing department, you know, just kind of double checking and making sure all the correct boxes, so that that patient doesn't, doesn't get any, you know, a bill, so let's see, I have two questions, I have, or a comment and a question, we have a Q&A question, and this is from Lisa, and she says, a few weeks ago, I provided care to a patient who was reporting an acute sexual assault, for which she was reported, reporting to law enforcement. Before discharge, she disclosed a second assault, also within the timeframe, for which there were other contract, contacts, and for which she was not reporting, I, she, I provided two sexual assault evidence collection kits, and completed two direct reimbursement claim forms, will the hospital be reimbursed for both forensic exams? That is a good question, and the very first place that I would start with this and getting that question is, I would reach out to the state's reimbursement process, so if it's the CDC, that's reimbursing for these, and, and paying for those, that would be the one who you would ask for that, the good, the, a good point of reference to know who to contact would be, who's going to pay for this, these exams, who's reimbursing, which agency, who's reimbursing, and they kind of want you to reach out to them with these questions, so because they, they're, from what I've noticed, a lot, a lot of states, they're very helpful in making sure that you understand, you know, the process and stuff, so I don't know this specific, you know, question, but I can really directly show you where you would find that answer. I've never heard of this scenario before, but I'm almost certain it's a scenario that could happen, but in this one, I would first check with who's the payer who's going to be paying, reimbursing this, and ask them those questions, okay, and then we have one other, let me see, is it a question or a comment, yes, so someone asked, a survivor can choose not to go through insurance and still be approved through victim's comp, so again, and I'm going to be repeating this all the time, that is also jurisdictional to where it happens, some, in some states, and I think someone commented that CDC is, like, they have to pay, you know, Medicaid, so, or bill Medicaid first, so knowing what your facility and your, two things, knowing what your state's process is when it comes to the way that you can or cannot fill insurance, and also knowing what the, what the facility's process in this CBC's process, like, I can't think of any specific, you know, right now where if they, if they don't go through insurance, well, yeah, yes, I actually, I do, so I did have a, have a case, and it was another situation where, it was another insurance situation, and I'm trying to get my thoughts correct on it, that patient's insurance was billed, and they found out that they could, like, they could have made the choice between if they wanted the state, and where if they wanted, and, but they had already charged this, if I'm thinking this right, give me a second, because I think my next question, I might have touched on that a little bit, with that one, when we get to the next scenario, give me one second, okay, and then one other person just commented, in Pennsylvania, they said patients can choose to bill insurance or decline, so there's an answer to that one for you, but I think in my next scenario, I think I addressed a little bit of this, too, so we'll see about that one, so our next one is a scenario where billed for services not received, so in this situation, we have a 21-year-old patient who visited a community hospital's emergency room for a medical forensic exam following a sexual assault, the patient arrived at the emergency department around 11 p.m., she was triaged, and was initially assessed by an ER physician, a urine sample was collected during this visit when the patient needed to urinate, and it was also sent for analysis, the patient was not informed of what testing was performed, or of the results, after the initial triage assessment, she was asked to wait in the ED waiting room to wait for the sexual assault nurse examiner to arrive, and after a four-hour wait in the waiting room, the SANE finally arrived, and she met with the patient, and she thoroughly explained the medical forensic exam, and offering her all of her options, but due to the extended waiting period, and by this time, it had been early into the morning hours for the patient, she declined, she declined the exam, and she considered returning later that day to complete it, but she was also, ultimately she was provided with information about, and resources to the local rape crisis center, and also the advocacy services, but ultimately, she decided not to return even later in the day for the exam, so three weeks later, the patient received a bill from the hospital, and the charges included the emergency room visit, the physician's services, the lab work for the urine test, and a consultation charge for the SANE nurse, and it amounted to about $3,000 for this patient, and so moving on to the next slide, so this will be another poll question, and so where would you start with this, the facility program billing department, the state CBC, or the hospital social worker? Yes, so almost 31% answered and almost everyone, 70% has it correct. You would start first with the facility program and billing department for this one. Okay, thank you all for answering that. So in this scenario, and this one, this was a large university hospital system. So the first person or the first department I reached out to was the hospital's billing department. I kind of, just because of the size of the hospital, kind of figured that their emergency room was probably utilizing their program billing department. And so, and I was, you know, very happy that I started there because fortunately the billing department manager was very aware that they had a process and a policy in place to process medical forensic exams and survivor care. And she immediately knew what the error was. And she reached out to, they, from that point, they actually facilitated themselves. This particular manager in this billing department, she reached directly out to the survivor, apologized, explained, and she connected them immediately with, so they, this particular billing department, they also, or this manager, had connections with advocacy for this state. And so she was able to connect this survivor directly with an advocate who was able to resolve the issue. And this was another one that before the end, I received in the morning, before the end of the afternoon, I was receiving a call back saying it had been resolved and the patient was, had not, you know, they had taken that off of her chart and things. And so, and when it was realized that the error was actually noted in the registration process in the emergency department and how the patient was triaged in the system and how she was discharged from the system. So you would be surprised if starting from the smallest things, like in this situation with the billing department, what other systems you may find that are in place that you may not be aware of. Because for this one, I'm sure even the emergency department didn't realize that the billing department actually had a process in place because, especially with the error and the registration process and everything like that. So in realizing these on my end, when I realize these and make these connections, I always make sure that, like in this case, the billing department, she was more than happy to educate and let the emergency room manager know that, yes, we have a process, this is what we do, and this is what we don't do. So those are always, always good for, like I said, when you reach out, you never know who may know something else more about the situation who can, you know, help make those connections. I will say when I do receive these particular type TAs, and I know it seems like a huge mammoth of, oh my goodness, it's a lot, like where do I find this answer? But it really, I think when I first started doing this, I think I was building it more up in my head. But once you start reaching, you just think about the first thing, who would you contact first? And somebody else knows something more than you do, or I did, and kind of like connected thoughts. So it's really, most times, a fairly fixed. And I will say, even when I receive these TAs in a call, like, I've never had any long drawn out, you know, resolutions or solutions. They're usually pretty fairly quick resolving. Okay, so a couple more questions or comments, I'm sorry. Okay, so someone's commenting, not eligible for reimbursement since it sounds like she didn't report to law enforcement. So there's, I don't know the, Rachelle put this, but she just put like a partial comment, it just says, and not eligible for reimbursement, since it sounds like she didn't report to law enforcement. So just based on this comment, just please correct me if I'm not understanding it correctly. But I will say, it does not matter how the person, the patient or survivor decides to report, they will be reimbursed for their services. They still should not be billed. The law states, all exams should be covered, you know, free of cost to the survivor, regardless if they decide to participate with law enforcement or not. And Corinne, I just put that in the chat as well, right? So yeah, that's just if they get STOP funds, they have to comply with the certifications and they have to certify that they are not conditioning humans on cooperation with law enforcement or participating with law enforcement or any aspect of the criminal system. I think that, I think the distinction though, in the chat was that someone did not undergo the actual exam. If they don't undergo the actual exam, there's no reimbursement because they didn't get an exam. And that may be, if I related to my last scenario in this particular case, she didn't really get an exam. She pretty much sat in the emergency room all day. But I think it was just because this particular hospital system, they had a system in place, right? And the manager, you know, was involved. And I mean, they could have said, hey, I'm not going to pay for this. You really didn't see anybody. But I think because they had that in place in that system, and they thought about it, thought about what to do in this case, that they were able to get her connected and get that even taken care of, because that would have been just, if they didn't, just horrible for her to sit there all that time. Yeah. So, okay. Okay, so then moving on, the next, someone mentioned that in PA, they will have the forensic exam paid, but are not otherwise eligible for VCAP services, oh, and so, yes, you know, I will. Thank you for that, Debbie. That is a little side piece that I did not add to that. In some states, if they do not report their crimes, victims will not reimburse for the, I think it's the victim services aspects of it, exactly what Debbie said. So thank you for bringing that, yeah, that part is true. And then someone else said, okay, Solana says, we are having a hard time getting our hospital to understand the importance of addressing these billing issues. There is no fine or penalty for hospitals in my state who will bill patients. Is there anyone on the government level I can report issues to who can maybe apply pressure from the outside? That is a very good point. I don't know if Farrah wants to add to that. Yeah, I would say this, Solana, if you could just email me, my email address will come up at the end. It's my name, farrah.gold.usdoj.gov, I'll put it in the chat. Just email me and then, and let me know where you are, what state, and I will, I will find out who the SOP administrator is and figure out how that works for you. And then Debbie also just commented that they will pay for the counseling or counseling only. Okay. So, I'm going to move on to our next slide. So this was our last scenario, however, I'm going to go back to the insurance, because I don't know why I thought I had maybe some notes in there and remembering the one I was saying with the insurance and in this particular case, this patient, she was actually charged, she was sent a bill for services that she received in an emergency room. And she was a student, a campus or a college student, and she had their college like insurance. And so what happened was when she received the bill, the first thing I did was I actually reached out to the crime victims of this particular state. And I want to say this happens in Maryland too as well. But I reached out to them and, and somewhere in that, she found out that her, the campus insurance that she had would actually cover for the exam and, you know, related services. And I think what was up was that these were like related, related bill services. So like her whole, like the forensic exams and all of the main components, the kit and all of that was covered, but this might've been like some lab work or it was some out, you know, ancillary stuff to the medical forensic exam. And so, but she found out that her insurance would cover for all of that. However, she still declined to use her insurance and went with the filling out for reimbursement to crimes victims because her insurance company made the process so very difficult. So they told her, yes, you can, we'll, we'll do that, but you got to do, she had to do fill out all of these forms. She had to go back, have the doctors fill out the, it was just not a friendly, easy process. Good to know that they would, but it wasn't, it didn't help her. So she eventually did decline. So, and in that case, like I said, I knew that there was a possibility where they were able to do both and, and bill the insurance. And also she was also able to receive services if she, if she wanted them through crimes victims. So my last question or this challenge or, I mean, discussion question is if you can, some people can respond or some cannot, is there any incidents that you can imagine where a patient received a bill that we haven't covered here that you would like to share? Either it happened or that you can imagine that happened. And while we're putting those in, I see a couple of questions and I'll look at those. So, Adrienne commented, and she said, in the last scenario that we just went over, a victim in her state would absolutely be responsible for that bill. There would be no reimbursement to the facility for the exam, and they would not be eligible for CDC. Just want to verify, there are no other options because of my state's laws. If you can just put in the comment, Adrienne, was it the very last one, which scenario, the very last one, I'm not certain when you put that in, and then what state are you from? Oh, so she's in West Virginia. And she said it was the scenario where the patient didn't receive an exam. So, yeah, and you're right that, I mean, unfortunate that, you know, but that does happen. And so in this case, I would just ask you, Adrienne, in this case, and the patient came to you with this, whether they decided to report or not. And I will say, I believe this particular, on follow-up with this patient, I think she eventually did end up going and reporting, but she never did the exam though, but she did eventually end up going and reporting. So with this one, if the patient report, for them being able to apply for CVC, do you know if West Virginia is one of those states where they have to cooperate or they have to report to law enforcement? Yeah, so she says they have to report to law enforcement or they have to have a medical forensic exam. So, yeah. So that's one of the ones, cause my next thing, so say she's in a state or say the survivor is in a state where it's not dependent on them reporting, I would definitely refer her to crime victims for services to get reimbursed for related. In any event, in all of these, I would absolutely refer this patient or make sure that this patient is connected with some form of advocacy or victim services. And even if they decide down the line for counseling or things, but just letting them know that they're connected, if maybe down the line, they decide that they want to report or if they want for further counseling or things. Okay, so I'm gonna look at one more. We have three more comments. And it looks like Jala, her name says, patient bill at the initial facility, ER, visit charge, et cetera. Then the patient is transferred to another facility for the evidence collection. And PA, the law states any medical provider can or should collect evidence and that specialized training is not required. So that's good to know too. Sounds like she was just giving us a fact about what Pennsylvania does. So that's good to know too. Okay, and we have three Q&A questions. We already answered those. All right. Okay, so if there's no more responses to this question and I don't think we'll get any more, we'll move on to the next slide. So challenges and solutions. So the next few slides, we'll talk about what do you do? What are the challenges and how do you resolve them? And so these are just a little bullet point of some of those challenges when it comes to medical forensic exam and payment and reimbursement. And the one thing is there's no universal reporting language or process for the medical forensic exam. Law enforcement involvement requirements, there's no uniform process for that. Kit types, so you have the anonymous, restricted, unrestricted, all of those are different everywhere too. And then one of the big things when you're talking about the actual billing process of the technical with filing the code. So almost every state in their process, they follow the invoicing and billing guidelines that Medicare and Medicaid follow. And they have to use what they call the billing language, which is using ICD-10 codes and CBD codes. And it's a coding system based on numbers that we use to identify diagnoses and conditions. And it kind of talks a language on how that patient was treated. So the thing with that is, and it's super critical in doing these billings for sexual violence or domestic violence or any assault codes, there is no universal procedure terminology code. It's inconsistent across the states, statewide medical forensic policy programs and billing subgroups. Everything is different as far as like who uses these processes. So for an example with the no CPT code, like how do we do those? So right now what the process is, we use CPT codes where that kind of includes some of the things that we do for this patient population for that relate to abuse codes. And then the other thing is, which I tell all of our providers is also about documentation and specifically talking to the providers who document these assessments, but how you document and how you word helps billers and coders a lot, trying to identify which codes to use and things like that. So what are those solutions? Let's go to the next one. Oh, I'm sorry, I didn't finish going down. So the insurance billing. So that's one of the other challenges that we have. And because some programs will, some programs, and I was recently asked about this, want to be able to utilize in their state that option if they have that they can ensure that they can bill insurance, the billable items. So, and then even in that process is also different in how that happens as far as like the actual submitting of the invoices and things like that. And it's different everywhere. So that's another huge challenge. The other issues we have with the insurance is issuing the explanation of benefits. And then we also have to consider what we call billable items. So billable items, when we're talking about those services that are related to the medical forensic exam, you have the medical forensic exam and you have some items that are automatically included. And then you have those, which we call billable. So those are the lab services. You know, you can be billed for labs outside. It could be medication. It could be the prophylaxis. It can be the antiretrovirals dealing with treatment for HIV prophylaxis. And then a new one that we're finding in some states are trying to include this in, but it can even include an assessment or treatment for strangulation. There's only one state right now that is including that in being reimbursed and that's Washington state. But some states, that's a separate, that's a non or a billable item to the patient, which is just horrible, but anything related to any type of assessment or treatment, that's not a sexual assault exam. That's not related to specifically a sexual assault. Okay, so there's a couple more questions and comments. We'll look at the questions first. Okay, so Adrian asks again, what is considered related medical treatment if prophylaxis doesn't count? So for instance, it would be that follow-up care that you have to follow up with, like for MPEP, getting the lab work and things like that. So it may only cover like that first dose, but when they go back to get those second doses and they have to get their lab work and stuff, those services might not be covered. Did that kind of explain a little bit? Okay. I wanna clear the questions I answered because I think that's what was confusing me. We really only have one question in that chat. Okay, and so then we have more comments and we can see what these are. And so Debbie asks, based on Jayla's question, should the patient have to pay for the ED bill from the first hospital since the first hospital didn't follow state law? So I guess that would be, are you specifically referring to Jayla's question? I think she was commenting on, was that West Virginia? I think the question was about Pennsylvania where they don't have the requirements that anyone have specialization, but yet they transfer the patient to another hospital and then she got charged for both the original visit. And as we were sitting here, I was asking some of my colleagues their thoughts. And the answer is that she shouldn't have been charged. But when you all are left with the fight that you've been describing the whole time, which I know is not helpful, but the answer is no, they shouldn't have been charged. Yeah, that's really, really sad. And a good thing is, and I know not everybody's, some programs are small, some are not, but a good thing would just be talking with people involved and as far as like making sure you have a solid policy and a solid process of what to do if we get a patient that comes in like this, like how do we handle those needs and just being really specific and firm on how you want to serve and care for those patients and what that looks like. So, and that's definitely based on where you work at and then how involved you are with leadership to make sure that they're hearing that part of it. Okay, so let's go to the next slide. Okay, so solutions. So yeah, educate. How can you familiarize yourself with what you can do to start in your jurisdiction or your area of practice? Create a billing support network in your programs like who do you call for support? A specific hospital staff member, a victim's comp person, a statewide SANE coordinator, whoever your point of contact is, and especially if there is a no SANE program in your facility or in your area. What does advocacy leadership, working with the billers to understand what needs to happen and then this also is gonna vary by state, but it's also important to consider what all is your program, like what the relationship is like with your program and how do you do your billing process? And then Jayla asked again, she said, who should I refer the patient to when they are charged? I always connect the patient to the victim services agency. I know this is happening across PA, yes. Who would you recommend the rape crisis center or patient contacts? Good question. So the very first thing, and it sounds like you are working outside of the facility in an advocacy capacity. I would reach out to the program or where the patient received the exam. That would be the very first place I would reach out to. And if it's an actual program, reaching out to the manager, to the nurses and the staff and letting them be aware because I'm almost certain in some of these cases, the actual program themselves didn't know that the patient had received the bill because the issue or what happened happened after the invoice left their site and their facility. So the very first person I would refer your patient to is to the nurse in the program that performed the exam. Oh, Debbie just said that was, that's okay, Deb. Debbie, you're okay. She said it was an error with her hand. Okay, so let's see. I don't think we have, okay. Oh, and she said, who would you contact outside of the hospital system? So another good place if you are contacted by a patient who received the bill would be your state's crime victim's assistance. A program would be a good place to start. Off the top of my head, thinking of that one, that would be, or another would be the state. If your state has a statewide SANE coordinator or victims advocacy service system, that would be another person that you would refer to. And then it also depends on the situation in the context of how they received that bill. Did they get a bill through their insurance? As an ELB, did they receive a direct bill from the hospital? And then in that, or for whatever services they received, whether it was from, in one particular instance, it was an outside lab service that had nothing to do with the hospital who were the survivor received the bill and so you would have reached right out directly to that lab facility. Does that answer your question enough, Jayla? I was also gonna say, and I think this gets the next slide, I could be ahead of myself, Corrine, but as I mentioned, the STOP statute is what requires states to provide these exams free of charge. And every state has a STOP administrator and they have to certify to the Department of Justice every year that they're not charging patients. And additionally, the statute itself requires that they coordinate with healthcare providers. So I've been contacting that STOP administrator because our recourse is freezing those funds if victims are getting these bills. I'm not saying that we're automatically gonna do that, but there are these STOP administrators, like I said, have to certify to us that these patients are not getting charged. And so I think going to them may be one way to do that because they have an incentive, the state has an incentive not to charge these victims because they want their money. Yeah, unfortunately. And then Jayla also commented, she said, PA does not have a state coordinator. PCAR is aware that hospitals are encouraged are not encouraged, I'm sorry, by regulatory agencies. And then she said, thank you. She'll reach out to STOP administrator. Okay. All right, so moving on to, and actually Farrah just already had started on this one and this is her slide. And I think we're over time anyway, so I don't wanna repeat myself, but I think that is a, I mean, I understand. And I empathize with all of the issues that you all are facing, but we do have these laws in place so we should use them, right? They require coordination with you. And like I said, they are the best interest in making sure that survivors are in charge. I mean, you just, I mean, we all wanna like, hope for the idea that I spoke with before that we wanna get justice for these victims. So we wanna encourage reporting, but at the end of the day, the states also want their funds. So thank you, everyone. Just a quick slides. And real quick, if you, I'll have my email at the end of this and the next couple of slides or the last slide. If you have any further questions, please feel free to reach out to us. One good thing is on the safetya.org website and on the iasnforensicnurses.org site, we have a new ask a nurse contact button. And if you just put your question in there, we'll be able to respond to your question directly on anything in any matters. If any other questions come up after today, just some, and like I just said, some additional resources, the safetya.org and the forensic nurses and our payment pages and references. And then I just like to say, thank you all so much. And this is me and Farrah's email address. Like I said, you can always reach out to me if you have any questions. And I don't know if Farrah had any last words. All right, well, thank you guys for joining us. Please don't forget to fill out the evaluation so that you can get your award at your CEs. And you all have a good afternoon.

medical forensic exam payments

sexual assault survivors

state programs

insurance providers

billing issues

hospitals agreements

survivors care

billing codes

insurance problems

support networks

advocates collaboration

STOP administrators