Tricare For Life Claws Back $100,000 Claim

[annon123]

Please accept my apology for lumping my response to you in the same post as my views on his diatribe.

You have empathy, he does not and acted like a complete jerk.

No problem. I really should read something before i reply or if I am unwilling to then just not reply since I didn't know exactly what went on - I just went by the short blub and had been there, done that, had the t-shirt so to speak.

I was a bit surprised by his response as well (and yes I saw his apology). I would hope agents would be compassionate when things go really wrong and understand how that emotionally, financially, etc. affects often already stressed out people. Yes the situation needs fixed which is critical, but often a kind word, some understanding, etc. goes a long way (and I'd imagine makes them more loyal to the agent as well).

 

[Medicare bro]

No problem. I really should read something before i reply or if I am unwilling to then just not reply since I didn't know exactly what went on - I just went by the short blub and had been there, done that, had the t-shirt so to speak.

I was a bit surprised by his response as well (and yes I saw his apology). I would hope agents would be compassionate when things go really wrong and understand how that emotionally, financially, etc. affects often already stressed out people. Yes the situation needs fixed which is critical, but often a kind word, some understanding, etc. goes a long way (and I'd imagine makes them more loyal to the agent as well).

I have no excuse for what I said. It was like 2am when I posted and was trying to be funny. I apologize to all on here. I hope those people find answers.

 

[annon123]

I have no excuse for what I said. It was like 2am when I posted and was trying to be funny. I apologize to all on here. I hope those people find answers.

Thank you for apologizing. I appreicate it. While some people find it funny (and depending on a friendship and how it is done some good friends may find it funny too) I don't find humor at someone's expense in situations like this funny. It comes across to me as mean and cruel. Again thank you for apologizing as there are some on this forum who would not do so and some of those I think wouldn't even understand why it's not funny.

 

[annon123]

Please accept my apology for lumping my response to you in the same post as my views on his diatribe.

PS I meant to put in my previous post that I know you don't deliberately say mean/cruel things on this forum like a handful of people do repeatedly across threads (which makes me thankful I don't know them in real life based on how they attack others rather than have an adult disagreement and I appreciate that you call them out on occasion for that behavior as well) and when you do help you don't first attack us for not knowing; that you are helpful to the rest of us and post useful articles and information that that is good for us to know. Thank you for that.

 

[somarco]

Back on track . . . from the linked article there may be some clues.


Tricare had retroactively denied 26 more claims for a total of about $3,000 worth of services it had already reimbursed providers for since 2019, when he first enrolled in Tricare For Life, a plan for Tricare-eligible people who have Medicare.

Harve has Medicare + TFL and has had both since 2019 (presumably when he turned 65). Medicare is supposed to be primary, TFL secondary. No word on whether the provider claims were properly filed with Medicare.

Tricare also reversed approvals for at least 10 claims, totaling about $100,400, for his wife, Janice, in the same time frame, while nine other claims that had once been marked as completed are being re-processed,

Janice is now 67, so has probably only been eligible for Medicare for 2 years . . . unless her MS triggered SSDI resulting in her possibly being Medicare eligible prior to 65.

Some MS therapies can run $60k to $90k per year.


Health Net Federal Services, the former contractor for the Tricare west region, also said it could not comment on specific cases, citing health privacy laws, but it said it is "actively looking into the matter."

TriWest Healthcare Alliance, which took over the contract this year, deferred comment to Health Net, which it said is responsible for processing and paying claims before Jan. 1. TriWest said it has not recouped or tried to recoup any payments from the Smiths and is not allowed to take such actions under its contract with the Defense Health Agency.

The plan administrator change didn't help.

Millions of service members, retirees, their families and network providers nationwide have felt cascading disruptions following Tricare's contract changes this year.

About 16,000 health care providers on the East Coast alone have not been paid this year, officials said, forcing many to drop Tricare patients, reduce their hours or consider closing their clinics. On the West Coast, federal officials said, beneficiaries are struggling with a host of issues, including long wait times at call centers and stalled referrals and authorizations.

Not good . . .


She said they called Tricare For Life, which is Tricare's Medicare program, but were redirected to at least three other numbers. When they finally reached a representative for the military's Defense Enrollment Eligibility Reporting System database, which holds information for every service member, Janice Smith said, they were told the officials had to manually fix her husband's records. The Smiths said database system did not elaborate on what was wrong with his records or what caused the apparent error. They were told to complete a Tricare form asking to reinstate their enrollment, even though they did not know whether they had been removed.

Makes you wonder why TriWest lost the contract. Perhaps they were always inept at record keeping. You gotta wonder what triggered an audit and recission on a $470 claim which seems to be the thing that started the snowball rolling.


Janice Smith said Tricare had initially approved her and her husband's services, which included brain scans to monitor her condition, hip replacement surgery, physical therapy and annual checkups.

This is very scary and doesn't speak well for TFL and their "beneficiaries".

 

[Medicare bro]

Back on track . . . from the linked article there may be some clues.


Tricare had retroactively denied 26 more claims for a total of about $3,000 worth of services it had already reimbursed providers for since 2019, when he first enrolled in Tricare For Life, a plan for Tricare-eligible people who have Medicare.

Harve has Medicare + TFL and has had both since 2019 (presumably when he turned 65). Medicare is supposed to be primary, TFL secondary. No word on whether the provider claims were properly filed with Medicare.

Tricare also reversed approvals for at least 10 claims, totaling about $100,400, for his wife, Janice, in the same time frame, while nine other claims that had once been marked as completed are being re-processed,

Janice is now 67, so has probably only been eligible for Medicare for 2 years . . . unless her MS triggered SSDI resulting in her possibly being Medicare eligible prior to 65.

Some MS therapies can run $60k to $90k per year.


Health Net Federal Services, the former contractor for the Tricare west region, also said it could not comment on specific cases, citing health privacy laws, but it said it is "actively looking into the matter."

TriWest Healthcare Alliance, which took over the contract this year, deferred comment to Health Net, which it said is responsible for processing and paying claims before Jan. 1. TriWest said it has not recouped or tried to recoup any payments from the Smiths and is not allowed to take such actions under its contract with the Defense Health Agency.

The plan administrator change didn't help.

Millions of service members, retirees, their families and network providers nationwide have felt cascading disruptions following Tricare's contract changes this year.

About 16,000 health care providers on the East Coast alone have not been paid this year, officials said, forcing many to drop Tricare patients, reduce their hours or consider closing their clinics. On the West Coast, federal officials said, beneficiaries are struggling with a host of issues, including long wait times at call centers and stalled referrals and authorizations.

Not good . . .


She said they called Tricare For Life, which is Tricare's Medicare program, but were redirected to at least three other numbers. When they finally reached a representative for the military's Defense Enrollment Eligibility Reporting System database, which holds information for every service member, Janice Smith said, they were told the officials had to manually fix her husband's records. The Smiths said database system did not elaborate on what was wrong with his records or what caused the apparent error. They were told to complete a Tricare form asking to reinstate their enrollment, even though they did not know whether they had been removed.

Makes you wonder why TriWest lost the contract. Perhaps they were always inept at record keeping. You gotta wonder what triggered an audit and recission on a $470 claim which seems to be the thing that started the snowball rolling.


Janice Smith said Tricare had initially approved her and her husband's services, which included brain scans to monitor her condition, hip replacement surgery, physical therapy and annual checkups.

This is very scary and doesn't speak well for TFL and their "beneficiaries".

Unless you have more examples, I cannot think of another case where if Medicare approved something Tricare denied it. I am no expert on Tricare, from my understanding it is like a plan F. Tricare will not pay anything that Medicare doesn't pay. Am I missing something? The article mentioned hardly brings up Medicare but instead focuses on TFL. So I guess my question is what does TFL do above and beyond what Medicare does not?

 

[annon123]

Unless you have more examples, I cannot think of another case where if Medicare approved something Tricare denied it. I am no expert on Tricare, from my understanding it is like a plan F. Tricare will not pay anything that Medicare doesn't pay. Am I missing something? The article mentioned hardly brings up Medicare but instead focuses on TFL. So I guess my question is what does TFL do above and beyond what Medicare does not?

Well medicare has a 6 year look back. Maybe they are recouping overpayments? Or retroactively denying payments? Or? without looking I think the article said it involves payments as far back as 2019 so that would fit. But then you'd think they'd be getting bills from the facility too. Well unless they haven't come yet.

 

[somarco]

I cannot think of another case where if Medicare approved something Tricare denied it.

I rarely run into TFL cases but have had 2 so far this year. And yes, Medicare A + B is primary, TFL picks up the spillover as long as it is something covered by TFL.

And yes, it is similar to the F plan.

Medicare is only mentioned twice which is not really surprising since TFL is the one retro-denying claims.

This situation seems like a typical govt SNAFU and the problems apparently did not start until TriWest took over the TFL portion from Health Net.

 

[somarco]

Well medicare has a 6 year look back. Maybe they are recouping overpayments? Or retroactively denying payments?

Medicare, which is primary, is not issuing the clawback, that is all on TFL/Health Net. According to the article, TFL has a 10 year look back.

The only provider bill mentioned is from a dermatologist (2020 claim date) but if TFL is clawing back claims from other providers this thing will snowball.

From my viewpoint, it seems the Health Net/TFL is the culprit to blame, not Medicare.

 

[annon123]

Medicare, which is primary, is not issuing the clawback, that is all on TFL/Health Net. According to the article, TFL has a 10 year look back.

The only provider bill mentioned is from a dermatologist (2020 claim date) but if TFL is clawing back claims from other providers this thing will snowball.

From my viewpoint, it seems the Health Net/TFL is the culprit to blame, not Medicare.

I sort of presumed since they didn't talk about medicare bills that was the case but then again if medicare clawed it back and the facility hadn't billed them yet they wouldn't know that yet. There is one place I go to that takes a good 2-3 mo to send out a bill after insurance has paid. And medicare isn't that prompt either from what I am seeing with someone else's issues.