Tricare For Life Claws Back $100,000 Claim

[somarco]

A Navy veteran and his wife said they were blindsided when Tricare, the military's health care program, rescinded over $100,000 in medical claims it had approved and paid several years ago.

Harve Smith, 71, received a $470 bill in January for dermatologist visits in 2020. He thought it was a one-off error until he discovered that 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.

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, according to records from her Tricare portal, which NBC News reviewed.

Tricare, a federal program, is allowed to rescind payments under its regulations, which permit recovery for up to 10 years in cases of overpayment or mistakes.

A Navy veteran and his wife say Tricare rescinded approvals for over $100K in health care claims paid years ago

The 71-year-old retiree says he has struggled to get clarity from the military’s health care program, as one medical bill has already gone to collections.

www.nbcnews.com

 

[Medicare bro]

They should call me. I could have this fixed in 30 minutes. I'm calling shenanigans on this article. The author never brings up the fact that if Medicare approved these procedures then Tricare would only have to pay 20%. And what on earth were these people having done that Tricare paid $100k? First of all Medicare pays crap, so this article is saying they had $500K worth of Medicare approved costs? LOLOLOLOL!!!! Hello Mr. Harve Steve, have you confirmed Medicare paid 80% of the original costs? Yes OK then Tricare has to pay! Oh so you and your wife had non approved butt implants? Yes you will need to pay that! Also Harve Steve is his name? Sounds like a horrible generic host of family fued.

 

[annon123]

They should call me. I could have this fixed in 30 minutes. I'm calling shenanigans on this article. The author never brings up the fact that if Medicare approved these procedures then Tricare would only have to pay 20%. And what on earth were these people having done that Tricare paid $100k? First of all Medicare pays crap, so this article is saying they had $500K worth of Medicare approved costs? LOLOLOLOL!!!! Hello Mr. Harve Steve, have you confirmed Medicare paid 80% of the original costs? Yes OK then Tricare has to pay! Oh so you and your wife had non approved butt implants? Yes you will need to pay that! Also Harve Steve is his name? Sounds like a horrible generic host of family fued.

They could have had someone with cancer treatment combined with CAR-T cancer treatment, etc. All of that can run a lot.

For example I had 4 rounds of chemo (supposed to have 6 but had to cut it short due to most of my bone marrow being killed so lots of infections/illnesses due to that until it recovered) that just the insurance adjusted cost (that I just now adjusted for inflation since this was a while back rate - and health care costs have gone up faster than inflation so this will be likely lower than the current cost for the same thing) would have been today $287,500 (rounded). Twenty percent of that is $57,500. If I had had all 6 rounds if would have been more ($431,250 adjusted for inflation, my 20% $86,250 if I had unlimited out of pocket). And that wouldn't have even counted the neulasta shots, being treated for shingles I got, 3 ER visits, additional oncologist visits, blood work, scans (CT and PET), meds (nausea, infections, etc.)...

The cost of CAR-T can run to a million plus counting hospital, that procedure plus what they do before and after the procedure (not counting chemo prior), complications... That could easily run to $200k TriCare would pay just with that. And in this case they were having multiple years of claims denied for both of them.

Having some expensive diseases, hospitalizations, etc. all add up. Multiply that by 2 people and you could get to that amount. Most people wouldn't but some would.

I know I am not a profit center for my health insurance but have never added up what I have cost them each year (never mind multiple years) - however if my out of pocket wasn't so low I am sure it would be a small fortune for me, let alone what was paid out on my behalf.

 

[somarco]

They could have had someone with cancer treatment

The article gives fairly good detail about the medical issues.

@Medicare bro sad to see you gloating at the suffering of others. Is this approach an effective sales tool for you?

Probably a good thing they didn't have you as their agent.

 

[annon123]

The article gives fairly good detail about the medical issues.

@Medicare bro sad to see you gloating at the suffering of others. Is this approach an effective sales tool for you?

Probably a good thing they didn't have you as their agent.

Agreed. And it isn't likely going to take any 30 minutes to do so. I would imagine it is going to be a long haul for them to get this straightened out - along with frustrating, discouraging and hard. And they may not win.

I got lucky when this happened to me. Five years later - yes that would be years - I finally won. I had told them I wanted to return my cancer treatment (this was cancer #1) like a couch since people make decisions on where to get treatment based on who accepts our insurance and they had accepted mine. Repeatedly. Over 7 months. I wouldn't have gone there had I known they were going to do this to me.

Meanwhile they cut off care. I found that out - along with the fact that they had retroactively unaccepted my insurance - when I showed up for yet another surgery - yes the day of the surgery. Because why would you possibly inform the patient who is coming from out of state 8 hours away in advance? Fortunately the surgeon (was an employee) argued on my behalf and I had the surgery. Then care was cut off. Good thing I had no complications.

It too me five years to get that straightened out and have them finally agree to write off what I owed them. I was incredibly lucky they did and it was not a sure bet they would. As they have no statue of limitations for bills in collection (as they are a state owned facility; out of state for me but their rules apply since I accrued the debt with them) this was not a sure bet outcome. It took lots of time, discussions, arguments, energy and mental stress... to win that.

 

[somarco]

@annon123 the stress of dealing with ups and downs of fighting for coverage and care.

Frankly, I don't understand the apparent lack of concern and empathy for clients who have to fight disease in addition to their insurance carrier if they want to get the care they need.

 

[annon123]

The article gives fairly good detail about the medical issues.

Sorry. I didn't read the article until after you said that. Having accrued zillions of dollars of medical expenses and been in that situation I didn't really want to read it - too many reminders of a really hard time. I did read it though after you said that.

I knew it was possible to have racked up enough in medical expenses to have that kind of copay if the insurance covering that wouldn't cover it. It puts you in a hard space. My examples were for the person questioning how it was even possible to owe that much (before copay insurance) to begin with (although clearly their collective list of medical issues were less one time events so to speak with chronic issues that, over time, can be expensive as it adds up). Clearly he has not had seriously expensive medical expenses or major issues that need untangled to due to retroactive actions to understand that this is not a fast or simple process to fix this kind of problem. Never mind care could be cut off if that is how the medical system that couple is using operates.

 

[somarco]

@annon123 I understand and appreciate your perspective and not wanting to revisit your past. But @Medicare bro not only made ludicous assumptions but proceeded to cast aspersions and make light of their situation which would not have happened if they had called him.

A rather pompous and asinined assertion.

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.