Well, hi everyone. And again, thank you for joining us for this webinar, the Medical Forensic Exam Reimbursement Framework, Understanding Payment Models and Funding Sources. Before we begin, I just wanna go over a couple of acknowledgements and disclosures. This webinar was supported by a grant awarded by the Office on Violence Against Women in 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. The authors, presenters, and planning committee for this educational activity have no relevant financial relationships with ineligible companies to disclose. Upon attending this course and webinar in its entirety, due to the criticality of the content and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is an accredited as a provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. And again, my name is Corrine Grzelik and I am, I'm sorry. My name is Corrine Grzelik and I am a forensic nurse specialist with the International Forensic Nursing. And in my role, I provide guidance and education on the national protocols, this adolescent and the adult adolescent national protocols. And I also provide guidance on issues related to the medical forensic exam and payment process. I'm gonna be joining this webinar today with Marnie Shields, the attorney advisor on the Office on Violence Against Women. And I'm gonna turn it over to her for her introduction. Hey everybody. I'm so happy to be here to talk to you about this topic. And I'm particularly happy to introduce the next set of speakers who are from the Government Accountability Office. We have Greta Goodwin, Sonya Ware and Sarah Williamson from that office, GAO for short. And the reason that they are here is that in the Violence Against Women Act of 2022, there were a number of provisions relating to sexual assault forensic exams. And one of these provisions tasked the GAO to do a study on a cost for forensic exams, how states were paying for these forensic exams and the kinds of things they were covering. And the reason I'm so excited to introduce them is that they went so far above and beyond the four corners of that requirement and they produced something that I think if you have not seen yet, you should. I very strongly encourage you to read it. It is very useful information and they provided profiles of every state. And not only did they include the state and territories, which is what the requirement was for, but they included an extensive discussion of Indian country and the complications and complexities of paying for exams where Indian country is involved. And with that, I will turn you over to my colleagues from the GAO. All right, thank you for that really nice introduction, Marnie, thank you, Corrine. And just thank you to this association for inviting us to participate. I am Greta Goodwin. I'm a director in GAO's Homeland Security and Justice team. And I manage a portfolio that looks at issues related to justice and law enforcement. And there is a focus, a particular focus on vulnerable populations and a lot of work around. But we're just really excited to be here today to talk with you about the work that we did. Marnie's talked with you about how we came to do this work. I'm gonna put forward our research objectives and then I'm gonna turn it over to my colleagues, Sandra Ware and Sarah Williamson to talk you through how we went about doing the work and some of the background, and then of course our findings. The objectives that we had in this case, we were looking at describing information about state and territories, looking at information about their requirements for covering the cost of sexual assault forensic exams and any other medical treatment that survivors would have if they were victims of assault. We were also looking at what medical treatments related to sexual assault would be covered by payers in the states and territories. And then third, we were looking at the challenges and any kind of promising practices that we saw within the states or territories where it related to payers, anything that they had experienced in ensuring that survivors were not billed for exams or related treatments. And then our fourth question looked at how much payers in those states and territories were spending in fiscal year 2022 for the sexual assault forensic exams and any related medical treatment. And as you can see, if you pulled up our report, the report was addressed to a couple of congressional committees, Senate Health Education, Labor and Pensions, Senate and House Judiciary and then House Energy and Commerce. It was a mandate done under VAWA, but these were our reporting committees and they were very interested in knowing what we found from the work that we did. And so again, we appreciate you letting us chat with you about our work. I'm gonna now turn it over to Sandra Ware so she can talk through the scope and methodology as well as some background. Thank you. Thank you, Greta. Yes, as Marnie and Greta just indicated too, this was a huge report that we did on this very important issue. And in doing that, we had a really robust methodology where we worked with a team of lawyers as well as methodologists in order to identify what's the best approach in order to answer those questions for this report. And in doing so, what we did was a 56 state and territory law and policy review. We also conducted a survey where we asked questions related to the costs associated with forensic exams as well as related medical costs. And in conducting that survey, we actually obtained a 100% response rate, which was pretty huge. We were excited to receive that. We also interviewed federal officials from many agencies, including DOJ, the VAWA office. We also talked to representatives from the tribal community for six tribal nations. And then finally, we talked to some local county level payers in three different states for a total of six of those that we talked to. And just to give you a little bit of background, kind of overall findings before I turn it over to Sarah, as you might expect, the responses that we see related to the payment for exams and related medical treatments vary. We talked to folks who were the head of federal departments and agencies that were investigating sexual assault cases. And some of them said that they sometimes would pay for the exams by either directly paying for them or by reimbursing the survivors of the sexual assault. We also spoke with the Health and Human Services, Indian Health Services and the Bureau of Indian Affairs and learned that sometimes they may be responsible for payments. We also learned that many states and territories rely on others within the state or territory to cover the exams. And then finally, at the local level, we also found out that some of the local jurisdictions require that counties and law enforcement agencies cover the cost of the exams. To go into a little bit more detail about our findings, I will turn it over to Sarah. Thanks, Sanja. Yeah, as Greta mentioned, we had four research questions. The first here, we were asking how many states and territories require that exams are paid for? And the answer is all of them. In most cases, you can see there on the slides, 47 out of 56, states and territories have a law that specifically states that survivors are not to be billed for their exams. And in our report, we have an appendix that lays out exactly what the legal language is in each state and territory. If you're interested in reading more about the specific legal language in a particular state, you can look in the appendix of our report. That's 47 out of 56. In the remaining nine states and territories, officials in that state certified to DOJ that they or another government entity pays for the full cost of the forensic exam. So they do that in a number of ways. And again, in our report, we go for each of the examples here on the slide. We talk about how they certify to DOJ that those exams are paid for. And we give an example here on this slide of Idaho. For example, they certify by naming the specific fund that is responsible for paying for exams in that state, the Crime Victims Compensation Account. So here, sorry about that, Sanja. Yeah, one back, thank you. So here, this is a figure from our report that shows very generally what each state and territory requires. That light blue shade, those are the states and territories that have laws specifically stating that survivors are not to be billed. The crosshatch pattern is those states where there's a requirement that additional treatments related to the assault, but outside the scope of the exam are also to be covered. For example, you can see there in the District of Columbia, there's a law requiring payment for the exam, but no additional treatments are required to be covered. But then just over the border in Maryland, however, this state requires both that the exam is covered as well as one or more additional treatments. So that's our first objective. Our second objective was to look at the specific treatments, which specific treatments are covered. So these treatments might be covered because they're required as part of the exam. They might be covered because they're required to be covered by a law in that state or territory, or they might be covered because the payers choose to cover them. As Sanja mentioned, we conducted a survey of officials from the payment entities in each state, and we asked them about what treatments they cover and why. And then we also conducted interviews with officials from a selection of counties and tribal nations. And the bottom line here is we found that in all states and territories, payer organizations reported that they covered at least one treatment that sexual assault survivors might need. So exactly which treatments were covered really varied across the county within states and across tribal lands. And on the next slide, I have a figure showing the results of our survey questions about specific treatments. So this shows, you can see the list there. It's a number of treatments that sexual assault survivors might need. And we show in the bars on the right how many states had payers that covered that specific treatment. For example, toward the top there, testing for sexually transmitted infections, testing for pregnancy, coverage for those is pretty universal. You can tell by that dark blue color, that means those treatments are covered because they're required to be covered in that number of states. But then if you look toward the bottom, coverage for treatments like mental health care, injuries, dental care are much less common. So you can see in that light blue color, many of the payers who reported to us that they cover that treatment reported that they covered it just because they choose to, not because they were required to. And for each of these treatments, we actually have an appendix in our report that shows which states covered those treatments. So if you're interested again in exploring a particular state or territory, that's in the appendix of our report. And that's objective two. Our third question in this report asked again about the challenges and promising practices for exam payment that payers experienced. So this slide shows some of the reported challenges that we heard about. For example, payers in some states told us that it was a challenge when neighboring states covered different medical treatments. So we heard a good example of this from New York and Vermont. In the state of New York, the payer in New York pays for exams regardless of where the assault occurred. In the neighboring state, Vermont, the payer requires that the assault occurred in their state to be eligible. Let's say someone is, their home is Vermont, they go to visit New York, they're assaulted, and then they return home to Vermont to seek treatment. Officials told us in that case, neither state, neither program would be able to pay for that exam. We also heard there at the bottom, that last bullet, we heard about some of the unique, specific challenges on tribal lands. For example, we heard that sometimes just based on the geography and size of tribal lands, survivors might need to sometimes travel hours in order to get to a hospital where they can receive treatment. We also heard a little bit about sometimes the relationship between tribes, tribal members, and law enforcement can sometimes be like a fragile trust relationship, and that might influence whether survivors report their assault or seek treatment. On the next slide, we show the, some of the promising practices that we heard. So for example, implementation of a single-payer model. We heard here from officials in Minnesota. Minnesota recently changed its payment model from multiple payers to a single-payer. And they told us that having a single-payer system really ensures that there's consistent and prompt payment to hospitals and care providers, and that it makes it easier to protect victims' private information. And then again, in the bottom bullet there, we talked a little bit about some of the specific promising practices that we heard for tribal nations. So we heard here about traditional cultural healing practices. We heard a specific example where advocates told us they would go and meet with survivors in isolated areas and have these traditional communal gatherings known as talking circles to communicate to them the resources that are available to them. That was our third objective. Our final objective here was about the money. How much do payers spend and what funding sources they used? So payers who responded to our survey reported spending about $93 million in fiscal year 2022 for forensic exams and related treatments. And in our report, we actually have a whole table that shows for each state and territory how much they reported paying in fiscal year 2022. So again, if you're interested in a particular state or territory, you can look to the report. In terms of funding sources, again, it was really a variety that they reported using at the state level. State funding sources most commonly used were either general revenue funds or a specific victims of crime fund. And then at the federal level, the most commonly reported being used there was the Victims of Crime Act Victim Compensation Formula Grant, which I think Marty's gonna talk a little bit about later. One caveat though here, that $93 million we show on the next slide, we know this figure is an underestimate for a number of reasons. And we lay some of the reasons out on this slide and I'll just talk about a couple of them. So for example, not all pairs collect data specifically about sexual assault survivors. So they might, for example, know how much was spent from the Crime Victims Compensation Fund, but they don't break it out by what the assault was for those people. Another reason going to that second bullet on the billing code, a forensic exam might include a number of different treatments, a number of different procedures and each one might have its own billing code. And those treatments and the billing codes might also be used for other kinds of examinations, not just people who have been victims of a sexual assault. So it's difficult to track using a billing code. And then finally, there also might be additional payer organizations that we didn't survey. For example, hospitals might choose to cover some of these costs. Some states allow insurance companies to be billed some of the costs for these exams. There are a handful of states that have county level payers. And although we interviewed folks at the county level in some of the states that do this, there were obviously several more. So we know that the true total of how much was spent was more than that 93 million. And just some closing thoughts for you. GAO typically audits federal agencies and we make recommendations to improve operations and save taxpayer dollars. This particular report was really focused on finding out more about the state's experiences. So we didn't make any recommendations here. And then the last thing I'll say is that in addition to the resources that I mentioned throughout my presentation, we also include at the end of our report and an appendix, a one page summary for every state and territory. Each one page summary includes information about what the law is in that state, who the payer or payers are, how much they told us that they spent for these treatments, what treatments they covered and any of the narrative experiences that they shared with us about covering these treatments. So we hope that those summaries are useful tools for any of you who are interested in learning more about how exams are paid for in a particular state or territory. And I will stop there and invite any questions. Marnie, I guess I can hand it back to you. It looks like we're using the chat for questions today, but none have come in. Yep, thank you. And thanks for all that information. If folks think of questions, feel free to go ahead and put them in the chat. I see a question already actually for you guys. Did you find that many states that allowed exam teams to be directly paid by the funding source? I think typically what we heard is that it's like the programs at the hospital, the same programs would submit forms to be reimbursed from the state organization, but maybe Marnie, what are your thoughts on that process? Yeah, I agree. It's more common for reimbursement. I think there might be some cases where there's a direct payment like that, but most often it's a reimbursement type process. And that actually flows nicely. It's a great segue into the next thing I'm gonna talk about. So Corin and I between us are gonna talk a little bit about a little more about some of the different ways that states have come up with to meet the requirement under the Violence Against Women Act that the state or another governmental entity bear the full out-of-pocket costs of sexual assault medical forensic exams. And I'm emphasizing a little bit or another governmental entity because the state doesn't have to be the one to pay, but it does have to be a governmental entity of some kind. And that's why in some cases they delegate it down to the local level because then it's still some kind of government entity that is paying. Next slide. The most common payment source is the Victims of Crime Act, which I'm gonna provide a little more information about. And then different types of state agencies or federal agencies sometimes have the payment responsibility. The Victims of Crime Act has two different formula grant programs that can be used for this purpose. And they are administered by the Office for Victims of Crime. And then they give funding to every state that are used for these two different things, the Crime Victims Compensation and the Crime Victims Assistance. The next slide has some more information. Most of the states use Crime Victims Funding, usually compensation, at least in part. So it might be like they use compensation and they use some additional state money, or they also delegate some things to the local level, et cetera. But by far Victims Compensation is the most common funding source. And the idea here is that it provides compensation to victims for a whole variety of things depending on the state. And so that could be like, the victim needs to change her locks. They would pay for that in some states. Could be medical expenses, but the idea is to help make victims whole by paying them reimbursement for the cost of having been a victim. And in some states, and for some of the expenses, the victim applies to whoever the state Crime Victims Compensation administrator is saying, these are my expenses, here's the bills. And then the state provides reimbursement to them. They cannot do that for forensic exams. They have to pay the provider, not the victim. The victim cannot be billed for the forensic expenses, but for the medical expenses, they can still reimburse the victim. But so in some cases, though, it's still a process. It might be a sexual assault nurse examiner program that's submitting a bill to the comp program. But in some cases, the state creates a separate fund that's called the Sexual Assault Victims Fund or something like that. But they're actually pulling the money out of Crime Victims Compensation. And then the second thing, the victim assistance is designed to fund victim service providers, for example, rape crisis centers to provide direct services. But those funds can also be used to pay for the cost of forensic exams. And in some cases they are, but it's much less common than the use of Crime Victims Compensation. And I see there is a question, is it true that VOCA funds cannot be used if the patient's insurance is billed? So VOCA is a payer of last resort. And what that means is that in general, if you have a federal source of health insurance, so for example, if you have Tricare or Medicare, Medicaid, those sources of funding have to pay before the Victims Comp kicks in. But in terms of Victims Compensation, as far as I know, there's no issues with insurance. But I think what you're thinking about with that question is that there is a provision that I think I do have a slide on coming up later in the presentation about the VAWA funds. And so there is a provision about use of VAWA funds with insurance that you cannot require insurance building if you want to use the Violence Against Women Act stop program funds, which is the program that has this requirement to pay the out-of-pocket costs for forensic exams. Next slide, please. So generally, as I mentioned, the purpose of Victims Compensation is to pay victims for expenses they've incurred. And so each state has a Crime Victims Compensation Program. And then separately under the Victim Assistance Funding, they have a Victim Assistance Program. Next slide. So I mentioned this one already, that Victims of Crime Act for Compensation is the payer of last resort. For Indian Health Services, they have a more recently enacted payer of last resort provision. Indian Health Services is the payer of last resort, which means that Victims Compensation would be used before Indian Health Services, but after other health insurance. And then I'm gonna pass it back to Corin to talk about some of the other examples of how states pay. Next slide, please. Thank you, Marnie. Before we go on, I just wanna make sure, were there any questions regarding so far of anything that Marnie went over or anything that you heard previously before we move on to discussing payment models? Okay, so it doesn't look like any questions for right now and if Sonya, if you're able to control this, I'm not able to control at the same time while I'm looking at my notes. So, I'll just let you know when I'll need this slide changed and then we can move forward. Okay, everyone. So, the next few slides, we're going to go over the different types of models that states use and each group will talk about the type and then talk about those particular states that are under and using those models. So, for the first one, we're going to be talking about hospital, state, health, and human services funds in those states. The first one that we have here, we're talking, we have Maryland that uses this and Maryland's model regulations ensure that doctors and hospitals get paid for taking care of sexual assault victims. They also, oh, I'm sorry, sorry. I'm sorry. My controls are going crazy here and it flipped my screen. Okay. So, again, like I said, the Maryland Department of Health, they handle their payments through, I'm sorry, let me pause one second to get my screen together with my notes. Okay, so sorry about that. Starting over with Maryland, the Department of Health. So Maryland, Department of Health handles these payments and for their medical providers, they just need to submit the proper paperwork to get reimbursed. This system helps victims access necessary medical and forensic services without worrying about the cost. So, under this model, their covered services includes the medical examinations and treatments necessary that are required in the medical forensic exam. And their reimbursement process is again handled by their Department of Health. And they do have some reimbursement eligibility requirements. And those are physicians and hospitals, they can receive payments for these specific services that are related to survivors of rape. And again, they have to have documentation that supports the services that were ordered. And there are specific forms and procedures that they have to use. And at the end of this too, I'll also talk about resources where you can find these state-specific documents and requirements. And for Maryland, there are no direct charges to victims. And then they also have a requirement for timely submission. And for them, claims must be submitted within 90 days for the care to be reimbursed. And then the next under this is New Mexico. So, they have, their funds are administered through their Crime Victims Compensation Reparation Commission. And they pay for 100% of the forensic medical exams per victim, per year. And then they will reimburse up to $150 on medical costs that are not associated with the evidence collection. So, they'll reimburse up to 150 for any injuries, insurance that may be needed for any injuries to that, and medications as well. The coalition, they send packets with billing instructions to medical providers who perform these exams throughout New Mexico. And again, I'll talk about where you guys can get these resources and links for each state. So, in New Mexico, again, their payments are made or reimbursed by the New Mexico Crime Victims Reparation Commission. It was started in 1981 under the Crime Victims Reparation Act. And it's also used to, as a source of financial assistance to victims and survivors for any out-of-pocket expenses that might occur as it relates to the crime or any out-of-pocket expenses that occur outside of the medical forensic exam. Okay. And then we can move to the next slide, please. And so, three more territories that also are on this. We'll start with the American Samoa. And in America Samoa, they don't have any codified laws related to payment for the sexual forensic exam. However, the jurisdiction has been paying for local survivor exams through funding provided by VAWA, which is the Violence Against Women's Act. And these funds are awarded through the American Samoa Criminal Justice Planning Agency. And through that, they provide reimbursement. So, in Guam, we have survivors are also, again, entitled to a medical forensic exam at no cost to them. The Criminal Injuries Compensation Program is what operates the payment reimbursements in Guam. And they do have a law that ties to that. And it's through their Guam Victims Crime Act. It's also through the National Victims Crime Act, I'm sorry, of 1984. But they have codified it into their law. And it's to provide reimbursement and payments to survivors through the Guam Crime Victims Compensation or the Criminal Injuries Compensation Program. Providers who provide these exams, they actually mail their claims to the Guam Attorney General's Office. And their healthcare coordination is provided through the Guam Coalition Against Sexual Assault and Family Violence. And in the Northern Mariana Islands, their programs and their reimbursement is all ran through their Commonwealth Healthcare Corporation. And again, patients are not billed for any sexual assault services. And the Commonwealth Healthcare Corporation or the CHCC, they provide the examination facilities and they fund the medical forensic exam. And the same program that they have at the Commonwealth Healthcare Corporation is not directly charged for patient care at all. And they receive reimbursements from the same program. Okay, so moving to the next slide. And so the next few slides, we'll talk about those states that are under law enforcement and prosecution funding. And starting with California first. On this slide, we have three states. So California. And California has a Victim Compensation Board. And it has jurisdiction, the law enforcement agency with jurisdiction is the agency that pays for the reporting victims' exams. And then with Colorado, Colorado is, they also have a program. Their program is called the Victim Emergency Payment Program or the SAVE Program. And it's also reimbursed by law enforcement agencies that receive the reporting victims' exams are paid by that agency and is divided up into by counties. And then moving to Delaware. Delaware also has a law enforcement model and their Victim Compensation Assistance Program, they actually have a policy that where they bill this insurance first. So they will bill a patient's insurance, especially if they're on federal insurance like Medicaid, Medicare, or if they have military TRICARE insurance, their requirement is that those get billed first, and then they will come in from their Victim Compensation Program and reimburse for funds outside of that. Next slide. The next we have Montana. And Montana, also a law enforcement agency that's investigating the crime or that the assault was reported to is responsible for payment. And same thing in Nebraska. In Nebraska, they actually have a Sexual Assault Payment Program, and it's outlined in the Nebraska Medical Sexual Assault Protocol that they have. So reimbursement for the medical forensic exam may be received by a healthcare entity who has provided the services. And then the entities must submit a data demographic form along with an invoice outlining the facility and the examiner fees. And then in order to receive reimbursement, they must be submitted no later than July 15th following the fiscal year ending on June 30th. So they have a requirement as far as time and when providers can submit for those. So Nebraska also has their requirements outlined into law, and they specifically mandate that, again, the full out-of-pocket costs for forensic medical exams are to be paid from their Sexual Assault Payment Program cash fund and that survivors or victims are not to be billed. And their reimbursement costs cover the examiner fees, the facility fees, laboratory fees related to any collection and processing of the evidence. And again, their Sexual Assault Payment Program is administered by the Nebraska Department of Justice, and it's under their Attorney General's direction. For Nebraska, they also have another little caveat where their program, which is actually into their law, their program will oversee the distribution of and payment of exams that occurred overseas and they were seen in Nebraska. Okay, and the next slide we'll be moving to is Texas. Texas and Wyoming are the last two states that actually are under this law enforcement and prosecution funding. And in Texas, they have, their payments are reimbursed through their emergency medical care compensation. They have two billing processes. So they have a section, they have a forensic evidence collection part, and they also have a medical part in both sections. So the forensic evidence collection covers what federally a medical forensic exam includes, which is the examiner's fees, the assessment, and the room or the space where the exam was taken, and the facility fees. And in their forensic section does include medications, but only for HIV prophylaxis. The other section, so the medical care for anything that occurs outside of that first part of their exam is covered under the medical care. Any treatments for injuries outside of that, medical medications, or any testing, all of those are covered under the medical side. And for both, there's two processes and they're built separately. But victims and providers are able to submit for medical costs and that, and they also will allow for law enforcement agencies to submit for cost of the forensic cost. So the forensic costs, again, that's like the, that's the kit. So they also allow for providers or law enforcement to submit for reimbursement for the forensic part, or if we're talking about just the kit and the things that go along with that. And again, forensic and medical costs are billed separately. However, survivors cannot be billed at all for the forensic portion. But the medical portion is the side where they receive medical care. And some of those portions of the medical care, survivors can be responsible for those associated costs. However, Texas crime victims compensation will allow for them to apply and get those costs reimbursed. Then the next one we have is Wyoming. And in Wyoming, the Wyoming Office of the Attorney General and the Division of Victim Services is the program that will pay for expenses and for that are incurred as a result of the sexual assault. And they cover for, again, like most states for those who will or will not report the assault to law enforcement. So their payment includes expenses for the emergency room, the emergency physician, the forensic evidence collection examination and kit, STI and pregnancy testing, and it also includes emergency contraception. So they also have a cap for their costs. So their total costs available for reimbursement can add up to $15,000 and that is actually in their statute. So the sexual assault, another note, has been or will be reported to law enforcement. If law enforcement is or will be involved in the medical facility, would follow the existing protocols for evidence collection and billing. The law enforcement agency requesting the forensic exam is responsible for payment of the examination. By their statute, they are the payer of last resort and they actually have that again in their statute. And it says the victim's insurance should be billed and an application for crime victims compensation must be filed on behalf of the survivor and that any expenses incurred other than the forensic evidence collection kit must first be billed to any insurance or any other resource, for instance Medicaid, Medicare, or if they have TRICARE military insurance. And only if there are no other resources that exist for that, that they will compensate first. And this is all included in Wyoming statute around their payment model. So next slide. For the next few slides we'll talk about those models that receive county funds. And starting with the first three, we have Arizona. And again, their exams are provided at no cost to the patient. And medical providers are actually prohibited in their statute from billing the exam, the cost of the exam to their, to survivor's insurance. Arizona, they don't allow you to even bill first or anything. They do, in their statute, it says insurances cannot be billed at all. And again, a survivor's cooperation with police is not necessary for the exam to be paid by the county. And in Arizona, those reimbursements are made by the Arizona Criminal Justice Commission Victim Compensation Program. It also provides financial assistance to the victim or to any family members who have been affected. It covers financial loss as related to the crime, including any healthcare costs. It covers expenses for physical harm, mental distress, and economic loss. And eligibility to receive the benefits from the program does not require the apprehension of the convicted, the offender. It does not, I'm sorry, it does not require apprehension or conviction of the offender. And the compensation program is always, again, with this state, they are the payer of last resort. Okay, so also in Arizona, each county's program has a compensation coordinator who is responsible for processing the claims and to collect supporting documentation from the providers or the survivor who was submitting the claims. They have an application process that begins with collecting all of, if any, police reports or any bills or any invoices. And yes, so that's that with that. And then next, we're going to Kansas. So Kansas, again, is another CBC program that is also county funds. So Kansas does not have a centralized billing process, and they, bills for forensic exam services are actually sent to the county where the assault occurred. The county where the assault occurred is responsible for the cost of the exam. The cost of the exams are conducted using a kit that is also free of charge. But then again, as with other states, the patient may be responsible for healthcare costs that fall outside of the actual kit. Medication or treatment for injuries that are not covered under the forensic exam may be eligible for Crime Victims Compensation. And again, it's the Kansas Crime Victims Compensation Board that provides these funds and financial assistance to survivors for any loss of earnings, for any of the out-of-pocket healthcare costs. And again, this also includes medical care, mental health counseling, post-care, and they even will cover for if there was a related death to the survivor. If the survivor died, they will cover those costs to any surviving family members. So in Kansas, they also have in their statute that they set a maximum. So they have a maximum of $725. That's for the evidence collection. And it's a maximum amount which healthcare facilities can bill the county for that. And that's also noted in their statute as well. And then moving to Louisiana. So Louisiana law, there are mandates that medical forensic exams and related services, again, are provided free to the patient. And that this provision ensures that survivors are not charged any out-of-pocket costs for the exam. Their funds are reimbursed through the Louisiana Crime Victims Reparations, and it's managed by the Crime Victims Reparations Board. And this is all under Louisiana's Commission on Law Enforcement. I'm going to pause because I see a couple of questions. I just wanted to look and see what those were. Yeah, so I can chime in. One of the questions was about Crime Victims Compensation asking how a state moves towards a model where providers can apply without a victim application. And I would encourage you to talk to folks in some of the states that have that model. I know Iowa has had that model for a very long time, but many other states do as well, where they have a, like I said, like a sexual assault fund that is pulled from the compensation fund. Then that facilitates easier repayment for sexual assault cases. The other one was a comment rather than a question, but it's great because it's an update on the information you were just reporting on Kansas Corrin, that they've had a recent update to their statute that has increased the cap and made it clear that reports do not have to be made to law enforcement for sexual assault. And that was effective July 1st. Oh, that's good. Amazing that they've changed that. Yeah. Okay, so then moving to the next slide. And these are the last two states that are under this county model is Nevada and South Dakota. In Nevada, the victim, again, must not incur any costs associated with the forensic medical exam. And that's also defined in Nevada's statutes. And in their statute, the county where the sexual assault occurred is the one that's responsible for cost. They pay for the initial medical care for physical injuries resulting from the assault within 72 hours of the survivor's arrival for treatment. They pay for the forensic medical examination conducted by the hospital. And then costs must not be charged directly again to the survivor, but they're charged to the county where the offense occurred. They do not require a law enforcement report. And they also separate, so they separate the forensic medical examination from the medical treatment or cost. And that is actually also in one of their statutes. In Nevada, forensic medical examination means the examination provided by the healthcare provider to collect evidence. And then victims of sexual assault or their spouses or family members may apply for, I'm sorry, may apply to the county to cover for any additional medical or psychological treatment. And all of that, again, is paid by the county. And for the requirement for that, the survivor also has to submit an affidavit to be reimbursed or have those services covered. And all of this is approved through Nevada's Board of County Commissioners, and they're the ones that process the application and reimburse. And then Nevada, they also have a cap. So, costs incurred by a hospital for approved medical forensic exam treatment, again, charges the county, and they will only reimburse up to $1,000. And any additional costs, again, must be handled by the hospital or the facility, which, again, makes them responsible for, they eat the rest of those costs. In South Dakota, they provide examinations with no cost to the survivor. And their cost is also covered by the county where the offense occurred. And then they have a clause in their requirements that says if the defendant is convicted, the county is reimbursed by the defendant. So, they impose a charge on the offender. And so, if they are convicted for the crime, they will then be the ones who will be reimbursed in the county for paying for these exams. And so, the county pays for exams, and what's included in their exams is the examination of the physical trauma, including the patient medical history, triage, and consultation, any evidence collection. They include in their clause what evidence was used to prove the They include in their clause what evidence collection means. So, that means photographic documentation, any preservation and maintenance of the chain of custody is also involved, any medical or specimen collection. And they also cover for alcohol or drug-facilitated sexual assault exams or kits. And all of this is codified into South Dakota's legislature, legislation. And so, I do have one little slide on here about Illinois and a little note about insurance funding. And I know we had, it came up earlier, and I believe, yeah, I'm looking, there's one more slide next to this one where Marnie's going to talk about that. And she can hit more if any insurance questions, but because it does get a little tricky with the insurance and what VAWA requires for those receiving STOP funds. But in Illinois, there is no direct billing to sexual assaults for medical forensic exams or transportation or follow-up. And they do prohibit including insurance deductibles. So, they prohibit collecting any insurance deductibles or co-pays or out-of-pocket. However, in Illinois, I'm sorry. Okay, so, in Illinois, they do require that with patients who are insured that the insurance company is, so the sexual assault survivor is covered by 1 or more policies or health insurance. They have to build the insurance company or that 1st with bill the insurance 1st before they will cover any costs. Any questions about Illinois, because I know that and like I said, Marnie actually is going next and there's probably be more questions as far as the insurance part of it. Yeah, and I see someone has a comment from Illinois that they do allow a survivor to opt out of the insurance billing if they are not the primary card holder, which is very good to hear. Yes, it might make sense for me to just jump ahead at this point. Yeah, because the next slide is yours too. Yeah. Yeah, you can move to the next slide go to the next 1 after that. Yeah, you can use the stop violence against women funds. This is what I was mentioning before. If 2 different requirements are made 1 is that insurance billing is not required and so this is similar to what Jacqueline in the comments was alluding to. You can still use insurance, but you just can't require it. You need to allow the victim to opt out and having them not be the primary card holder is certainly the biggest area of concern because then there's an that EOB statement that goes to the which is the explanation of benefits that goes to the card holder that might show expenses related to the forensic exam, which the victim patient might not want. The card holder to be aware of. So that's 1 thing and then the 2nd thing is that the exam had to be done by a specially trained examiner and it doesn't have to be any particular certification of training. For example, they don't have to be certified as a sexual assault nurse examiner or sexual assault forensic examiner, but they do have to have some specialized sexual assault exam training in order to qualify. So that's the insurance piece. The other issue is that if you do use insurance, the victim can opt out, but you allow them that it would still go to insurance if the victim does not opt out any of the expenses that the insurance does not cover need to be covered by the state or other governmental payment source without the victim getting a bill. And so that can be logistically challenging because typical hospital billing, whatever comes back that the insurance doesn't pay automatically gets billed to the victim. So there has to be some workaround in place that if there's a deductible or copay or things like that, it gets sent to the designated payment source and not to the victim. And then my sort of parting slide is just if any of you are involved in designing these processes within your jurisdiction or within your programs, just an encouragement to think creatively. A big change happened with the Violence Against Women Act of 2013. No, 2005. Sorry, there's been a lot of reauthorization. So in the 2005 authorization, the original requirement was changed to specify that the state cannot require cooperation with law enforcement or the criminal justice system as a condition for payment for the exam. Prior to that, because of the use of victims' compensation, a lot of states did have that requirement because in general, victims' compensation has that requirement that in order to be eligible for compensation, the victim has to cooperate with law enforcement. The OVC Office for Victims of Crime Regulations included a provision specifying that for victims of sexual assault, the mere fact that they got the exam counts as the cooperation. So even back then, states did not have to require cooperation if it was payment for a forensic exam. But many of them, that was just like, here's what our victims' comp rule says. It says you have to cooperate. They didn't do anything special for sexual assault. And what happened in 2005 required states to really rethink how are we going to manage the payment for these exams without requiring law enforcement or criminal justice cooperation. And so some states got really creative. I'm pretty sure it was North Dakota that had just like an insurance fund that they tapped into to pay for the exams. Interestingly, a lot more states actually shifted to victims' compensation than had used it before. But they did the things like the Iowa, what was then the Iowa model, and maybe one or two other states having a separate designated pot within the victims' compensation that was the sexual assault fund. And another creative thing I've seen more recently was in Louisiana that passed a law that had some unclaimed gambling winnings. And the state was tapping into these unclaimed gambling winnings as a way to pay for forensic exams. So there are different innovative ways of how to meet this. And I see there's a question, do you offer training or can you direct me to training for insurance and medical care billing for organizations looking to do that billing for the first time? I'm proficient in billing for the forensic exam through crime victims' comp in Texas, but the medical billing is new. Corrin can chime in on this, but I believe the website for this TA project has a number of resources that can be helpful on that point. And then also they asked, where can I get more information about STOP funds? I've never heard about that before. So in a minute, I'm going to turn this back over to Corrin, and I will pull you some information on our website that I will put into the chat. But it is OVW's largest program. It's a formula program that goes to every state and territory. They get a $600,000 base amount. Thank you, Sarah. They get a $600,000 base amount plus additional based on the population of the state or territory. And then there's a long list of enumerated purpose areas all having to do with violence against women. And they have to spend 30% on victim services, of which 10% is for culturally specific victim services, and then 25% for law enforcement, 25% for prosecution, 5% for courts, and then there's 15% that's discretionary within the long list of enumerated purpose areas. And what Sarah just posted in the chat is information about that program. And there's also, yeah, that's probably the best thing to look at is that link. Thank you. And I just wanted to chime in for Arianne who put in the question about the training. Also, at the end, we'll have the safetya.org site for that particular. So we don't have trainings, but IAFN and myself, we do offer specific guidance and how to do that and make those connections. And when you go on to the safetya.org site, we'll give it more information at the end of the webinar. There's multiple ways where you can reach right out to a forensic nurse and you can put in a request through our ask a nurse button, or you can hit the contact me button. So this would be pretty much just guiding you through the right departments that you would need to collaborate with if you're trying to start this system through your programs. I encourage you to just reach out to us through those means for more specific guidance on that. Thanks. And I see Sarah also put another creative example in the chat, which was officials from Kentucky reported using traffic school fees and court costs to cover the cost of exams. That's a great one. So thank you for sharing that. And so now I'm going to turn it back to Corin to talk about some of the challenges and solutions. I hit the. There we go back. There we go. Okay. So over the next few slides, we'll actually be ending the webinar with this. But as we all know, there are with any payment and billing model, there are challenges. We're going to go over some of those challenges and some of those possible solutions. We'll be talking about what do you do if a person is not able to pay their bills. If a survivor receives a bill or if they're receiving any bills related to the exam, any jurisdictional and reimbursement issues you have either where you've provided the exam in one state and the assault happens in another or even internationally. What do you do in those situations? There's questions and challenges that come up regarding survivor status if they are an immigrant or if they are incarcerated. And then you have multidisciplinary collaboration, which is extremely important. It's probably the key to answering a lot of your questions or challenges. So we'll discuss just some key points of that and then some resources. I want to start off by with a poll question. And I think Shannon's going to put the poll questions. Sometimes I do like to know what's happening on the ground and what solutions or what things people are doing. In this question, I'd like you to think about your area of practice. And have you ever encountered an issue where a patient or a survivor either received a bill for their exam or received any bills regarding anything related to the exam? And then if that was so in your practice, who did you contact? How did you get that through? The first question, who do I contact? Was it a program funder for A, the agency you submit your billing to? Your state crime victims compensation program? Either your program or your facility billing department? Or did you reach out to your patient's insurance, private insurance or state insurance? And I will give a few minutes for those questions. I don't know if it's, I can't see if it's that. I don't see the side Shannon where it's showing me if the questions were answered or not. Okay, okay, so it looks like most answers we have the big, the largest 1 is they reached out to the program in the billing departments. 1st, I want to say, none of these are like, wrong answers and depending on your situation, or what the issue was, it would depend on who you would reach out to and contact. This is just good for me to know. As far as getting an idea of where people reach out to, but program facility and billing departments. Would be your 1st place you would go to if a survivor approached you about receiving a bill. If your facility is the 1 has a billing department that's processes your, your claims usually that would be 1 of the 1st places you would check. With 1st, because the answer may have been an issue that started with the process, even submitting the invoices. So, thank you for that. So then we'll move to the next slide. Any questions about that 1 before we move to the next 1 again, and then starting with the next challenge, which would be international or across state lines. Usually when a medical forensic exam is conducted in a state different from where the assault occurred, including internationally. Regardless of whether the survivor resides in that state, or not the violence against women at mandates that the exam must be provided at no cost to the victim. And according to this, the federal statute on rape exam payments, states are required to cover the cost of medical forensic exams performed within their borders. Even if the assault occurred in another state, the law does not restrict states responsibilities to only cover exams of assault within their jurisdiction. Now, I say that because I know a lot of states actually have those mandates in their laws that they will only cover for exams that happened or for assaults that happened in there. But what the law actually says is that if they performed it, they're required and it also mandates that states and health care providers work together to resolve that issues. What does that mean? That means that you absolutely would have to reach out to there's a couple of when you're coming with cross state line or jurisdictional issues. You will want to reach out to 1st of all, your state payer agency that provides the reimbursement reaching out to them and trying to find it, find a solution. And then reaching out to the police department, if this is a reported case, the police department that's taking the exam. And then other solutions would be a reach out to the state saying coordinators, your state find victims or any advocacy agencies or services that are working with the survivor to help get the issue resolved. I guess what I'm trying to say with this 1 is, even though some states may have in their in their mandates that they're not going to pay because the assault didn't happen there. If we're leaning on the federal statute, what the federal statute says is that states have to pay and health care providers have to work it out and have to come up with a solution. So, that takes a lot of advocacy on your part with for the patient and a lot of talking with your own state payer and getting those issues resolved next slide. Please. And so now the other challenges that you may come across in this is our immigrant survivors and incarcerated survivors. Again, this can look different based on where you are jurisdictions based on what they're what they're lost or what their laws say. However, again, the federal statute does not status does not determine access to free exams based on a patient status and that states again are required to cover these costs. And that the law does not limit the state's responsibility to provide these exams to a sauce that for patients that are statuses is this is the same as with the jurisdiction. The state says, if this are the statute says that the states provide the exams, they actually have to cover those costs. And again, but this one solutions educate and then the multidisciplinary collaborations if issues like these are coming up in your practice. And there's a question of if this exam is going to be covered because of a B and C, the first or because of immigration or if the patient is incarcerated. The first thing you want to do is With incarcerated, you want to reach out to their facility that is responsible for their care. So that would be the first person you would or the first department, you would reach out to and talk with them. Agencies or your state payer, whoever is the main payer who's providing these and then same thing with any immigration or immigrant patients, you would reach out to your state payer. The first thing would be The who is responsible for paying the bill when issues of immigration or incarcerated survivor comes up, who is responsible because usually collaborating and talking with them because they also know what the federal law is those issues could be can be resolved. Okay, next slide. And this is also just to piggyback on the other one. As far as education and with multidisciplinary educate. We actually first have to educate and keep informed of ourselves and where your work area and where you are, your laws and policies around your work areas in your facility in your program first and then outside of your facility into your jurisdiction. Knowing where you can find those resources, creating a billing support network. And so what does that look like or a multidisciplinary team? What does that look like? This would be your other nurses and departments internally on your emergency room departments and managers. This would be Any Departments that are involved in your billing process. So medical billing departments, you would also want to include into your team or your multidisciplinary network a state, any statewide saying coordinators or if your state has one, any of those and then also your payer, whoever your program payer is, or your state payer, those are People from those boards. You want to also incorporate into your billing network, creating these teams. They actually even help you Ensure that your program or facility policies are in line with federal processes or federal mandates and then it also even gives you a chance to even look and see where there's any loopholes or any drops in the process that may need to be improved with policies that you would implement into your own Program. Advocacy or advocates are really big with this adding to your team as they are really the first ones who were if a survivor receives a bill or has any issues related to Their medical forensic exam, they may be the first ones in contact with so Educating advocates about the process and then educating ourselves through the advocates about that because a lot of advocates know about that process because they are Again, some of the first ones who are contacted when there's an issue that goes on with survivors and receiving bills or any type of payment related issues. Okay, and then next slide. So this is so on the safety a.org we have an interactive resource mapping is a state by state map. It has All of the state's reimbursement guidelines and protocols and laws. If a state has one on all of the billing information that they would need. Regarding the billing process. So how to fill out forms what billing codes to use. We even have a lot of information on that as well. We also have states reimbursement amounts. We had mentioned earlier before that a lot of these states. Some states have caps and some don't, but we have all of that information and resource on safety a.org along with eligibility requirements and each state's application process. And then we also have a lot of information on coordination with health care. That's a big thing. And even the solutions surrounding all Exam payment processes is coordination with other health care and multidisciplinary collaboration. So we also have under each state information about that. And in those states, who would be Who you would coordinate with in in helping with any of these issues. And then we also have a lot of just miscellaneous state specific information per state. So if there's a Anything particular in a state, for instance, just off the top of my head, Texas has a bill twice. It's separate billing. So we have a lot of information related to that as far as Texas. And I will say You are actually help us keep this pretty much updated. So please take a look at it. And if you're going through. And if you notice any updates about your state or anything on there that may be even outdated or Any new things like how it was earlier mentioned in the comments about something new going on in Kansas. So we encourage all of that information for you guys to send to us. And again, on this site, we make it very easy and accessible for you to reach out to a forensic nurse specialist. And like I said, we are opening it and accepting everything. Next page, please. I think this next page is all about is the exam payment, which is another payment to a resource. So when you go on the safety a.org and you click on exam payment and we'll bring you here where we have payment fact sheets. So a lot of our fact sheets. We actually have two new ones that came up. That are surrounding payment issues or the process with incarcerated survivors and we have one that is totally dedicated to immigrant survivors. The immigrant survivor one is really good because it also talks about resources healthcare resources and connections for survivors who are immigrant past the sexual assault survivor. So it actually is a lot of information on that. Our payment research page talks about all of the recent researches that are coming up or that are involved around payment exam. That's where you will find the new GAO report that we just talked about here. You'll find that under there as well. And then payment news is just updated news on anything that's up to date or anything that's new that's coming up. hotline, our email, and again, you can go on any of these pages and you can have access to all of these. But if you have questions, requests for specific guidance related to your program, we are more than happy to walk you through those. And again, you can reach out to us by the contacts here on the page. I see a couple of questions. So now, any questions? We have a few minutes, we can do a couple of questions. If you want to scroll to the last slide, it has the email addresses for both Corinne and me. So if you think of any questions that you have later, feel free to email us. And I see it's also just been added to the chat along with the evaluation link. Thank you very much. And again, thanks so much to our colleagues from GAO on both producing that amazing report and in thank you for coming today to present about it. This webinar was recorded and will be shared on the IFN's website so that more people can hear about it as well. Thank you. And then I see Sarah put in her email in the chat real quick. If anybody has any questions for GAO, I will also make sure we have their contact information on the website for if you guys have any questions for that too, related to the report. But thank you guys for attending. Wish everyone a happy afternoon.

Medical Forensic Exam

Reimbursement Framework

Payment Models

Funding Sources

Violence Against Women Act

Crime Victims Compensation

State Payment Models

Forensic Nurse

Government Accountability Office

Multidisciplinary Collaborations

Victim Advocacy