My doctor says I still owe more
November 10th, 2009 | TriCare Help | Posted by Military Times
Q. My doctor’s bill was $267. I paid him the amount Tricare allowed, $173.82, plus an additional 15 percent. That should have paid his bill in full. Apparently, it didn’t. I am getting bills from them that say “Balance due: $67.10.”
I could pay him that amount, but I don’t think he is entitled to it. I explained to them that I had paid the amount Tricare allowed plus an additional 15 percent. That is what you have explained in your column. I showed them the Tricare Explanation of Benefits so they could see it themselves. They told me this rule applies only to Medicare patients, not to me. Is that right?
The only information I have is what you report in your question. Based on that information, it appears you have paid correctly.
The 15 percent rule is a provision of Medicare law called the Limiting Charge. It says that a nonparticipating provider may charge a Medicare beneficiary up to, but not more than, 15 percent over the amount Medicare approved on the claim.
Congress passed a law applying the Medicare Limiting Charge to Tricare claims beginning Oct. 1, 1993.
But you will never be able to persuade your doctor’s office that you and I are right, and they are wrong. Here’s what you need to do: Write a letter to your Tricare claims processing office at the same address where you submit claims. Explain the situation to them. Attach a copy of the EOB for that claim and copies of the bills you have received.
Tricare will contact the doctor’s office on your behalf and explain the law to them. In most cases, that will resolve the issue. If it doesn’t and the doctor’s office has really dug in its heels, send me another e-mail.
What if Tricare pays in error?
November 9th, 2009 | TriCare Help | Posted by Military Times
Q. Let’s say Tricare finds out after six months or a year that it paid a claim in error for a dependent. Will it ask for its payment to be returned? If so, who would be responsible for repaying Tricare — the provider or the patient?
If Tricare pays a claim in error, federal law requires it to recoup the money. It will ask the payee on the claim to refund the erroneous payment.
If the provider participated in Tricare on the claim and received payment directly from Tricare, the provider would be asked to refund the payment. If the provider did not participate on the claim, payment would have gone to the adult patient or the custodial parent of a minor child, who would be responsible for repaying Tricare.
When Tricare determines that a claim has been paid in error and requests a refund, it is because the claim was denied. Whoever is asked to return the payment — the adult patient on the claim, the custodial parent if the patient was a minor, or the participating provider — may, and should, file an appeal of the denied claim.
Tricare has only one concern and one responsibility: the return of the full amount of a payment made in error.
Why were we billed for hospital stay?
November 3rd, 2009 | TriCare Help | Posted by Military Times
Q. My wife and I are enrolled in Medicare Part B. Medicare and Tricare for Life have been paying all the bills. Now she has received a bill from the hospital for emergency room treatment. The bill says Medicare and Tricare have paid their shares and we owe $153. Is there a logical explanation for this bill?
I have no way to gain access to your Tricare claims, so I couldn’t do more than speculate about the reason for the balance due. But, I can tell you how to get the information.
Write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Explain the problem in detail. Because your wife was the adult patient, she must sign the letter (Privacy Act stuff). Include her full name and her Social Security number, your full name and SSN, home address, a daytime phone number for her, the name and address of the emergency room, and the date(s) of medical care.
Every time a health insurance plan processes a claim, it issues to the patient a full report of each action it took on each of the medical service charges submitted. On a hospital claim, there may be dozens, even hundreds, of them. Most plans call their report an Explanation of Benefits, or EOB. Medicare calls its report a Summary Notice.
Include with your letter to Tricare Management Activity a legible copy of each EOB and Summary Notice your wife received from Medicare and Tricare for all the charges related to her emergency room care. It is important that each charge submitted to Medicare should be reported on both the Medicare Summary Notice and the Tricare EOB. That is so TMA, in its search for an unpaid $153, can trace each charge to determine the way it was processed.
How can I find out if Dad is eligible?
September 25th, 2009 | TriCare Help | Posted by Military Times
Q. My father retired from the Navy reserves with previous active duty after 24 years. When he retired he was informed by the Navy that he was enrolled in Tricare and that he just needed to take his retired ID card to the VA for health care. He is retiring in three years from his civilian job, and they pay 70 percent of his health care costs. He won’t be eligible for Medicare Part B for another year after he retires from the civilian world.
Does he have Tricare? Can he get it if he doesn’t? Can Tricare be a secondary carrier to pick up the 30% his employer doesn’t pay?
Tricare is a federal health benefits program similar in that respect to Medicare. Eligibility is established by federal law for certain categories of people, including immediate family members of active duty uniformed service personnel, uniformed service retirees, some retiree family members, and survivors of deceased active duty and retired personnel.
Only the uniformed services may determine whether a given individual meets the legal criteria for Tricare eligibility, register an eligible person in the Defense Enrollment Eligibility Reporting System (DEERS) database, and issue an appropriate uniformed service identification card. Please contact DEERS, toll-free, at 1-800-538-9552. to inquire about your father’s Tricare eligibility. You may be unable to get the information due to Privacy Act restrictions, however. If you have a problem, ask DEERS how to resolve it.
DEERS is a federal agency and part of the Defense Department. All information in the DEERS database is protected by the Privacy Act. DEERS deals with Tricare eligibility only. It is unable to provide information about Tricare benefits or claims.
Tricare and medical services received from the Department of Veterans Affairs (VA) are totally unrelated, however. Although both are programs under auspices of the U.S. government, they were created and are governed by totally different laws. If the VA beneficiary is charged for any services received from that agency, Tricare cannot pay for it unless the VA facility has a special arrangement with Tricare, which few do.
By federal law, Tricare is always last payer to all other health insurance (OHI), medical programs such as an HMO, or medical payments such as one might receive as the result of auto accident insurance, or proceeds from a slip-and-fall injury, and the like.
If your father is eligible for Tricare, so is his wife and any unmarried children under age 21, or under age 23 if the child is a full-time student at an accredited college or trade school. If your father is divorced, his former wife may be eligible for Tricare. Ask DEERS for more information in that case.
Your father (and other eligible family members) must file claims for health care with his OHI first. When the OHI completes all processing and issues the patient an Explanation of Benefits (EOB – the final report a health insurance plan issues regarding all its actions on the charges on a claim), the patient may file a Tricare claim for any unpaid balance.
As second payer, Tricare will usually pay part, or often all, of the OHI’s deductibles and copayments. Tricare will issue the patient an EOB when it completes processing. The EOB will report the amounts Tricare paid of the remainder after the OHI paid its maximum. If any amount is still due to the provider of care, the Tricare EOB will report that amount.
Here is how to file a claim with Tricare as second payer to OHI.
1. Complete an official Tricare claim form DD2642. Tricare’s web site can help you with claim filing and give you contact information for the patient’s Regional Tricare Office. The patient should keep a permanent record of that information.
2. Attach a photocopy of each of the itemized bills that were sent to the OHI. An itemized bill is the paper that lists each of the medical services the patient received and the charge for each service. A “balance due” bill cannot be used in place of an itemized bill.
Either the patient or the provider may file the claim, but the patient must sign the claim form. A claim for a hospital’s services must be filed by the hospital. Please note that the bills for a physician, surgeon, radiologist, pathologist, anesthesiologist, etc. are not “hospital services,” although the care was received while the patient was in the hospital. Such people are called individual providers and will bill separately for their services.
A hospital bill includes services and supplies provided by the hospital, and payment should go to the hospital. They include such things as room and board; special diets; general nursing services; use of the emergency room, operating room, recovery room or intensive care unit; use of the hospital’s imaging services and personnel (such as an X-ray or MRI); use of the hospital’s laboratory services and personnel; drugs; gases; blood; and delivery equipment such as tubing or needles.
3. Attach a copy of the OHI’s EOB(s) that reports its actions taken with each of the charges on the itemized bill.
4. Make a copy of each document for your records.
5. Send the packet to the appropriate Tricare claims processing office.
Note: Check the copy of each document submitted to be certain it is legible, including all words and numbers on the bills and EOBs. Complete the Tricare claim form carefully. Uncle Sam likes things neat and easy to read; it minimizes errors, thus saving time.
Allow Tricare at least four weeks, door to door, for processing. Respond promptly to any requests for additional information. If a Tricare claim is denied, the reason will be stated on its EOB. If a denial reason mentions DEERS or eligibility, call DEERS immediately at 1-800-538-9552.
If the reason for denial of a claim cannot be resolved quickly, say, by telephone, the patient has 90 days in which to file an appeal. The appeal must:
- be in writing
- report the specific matter in dispute
- contain a copy of the Tricare EOB reporting the denial
- and be signed by the adult patient.
It should be sent to the address of the claims processing office that issued the EOB reporting the denial.
Mixed messages on cancer treatment
September 25th, 2009 | TriCare Help | Posted by Military Times
Q. I have been diagnosed with prostate cancer and I am considering High Intensity Focused Ultrasound as my treatment option. I will be traveling outside the U.S. for this treatment since it is not approved here. My insurance is Medicare and Tricare For Life. Medicare will not cover anything outside the U.S., and initially Tricare has told me they will not cover it. However, I have spoken with several people who have Tricare who say they have been reimbursed for this procedure. How I should proceed?
First of all, I can give you only unofficial advice on this matter, since I have no official relationship with Tricare or the Defense Department. Neither I nor my published works should be considered as representing or speaking on behalf of Tricare.
You should contact your Tricare claims processing contractor to ask for an opinion about whether the procedure can be covered by Tricare, but I don’t know whether one will be forthcoming. I think that for Tricare to say the procedure will be covered could be considered to be a prior authorization, which Tricare is not allowed to provide unless a prior authorization for a procedure is required.
Failing a reply you consider adequate from the Tricare claims processor, I recommend that you write to the Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. (The Tricare Management Activity is a federal agency under auspices of the Office of the Assistant Secretary of Defense for Health Affairs. It is charged with certain management and/or directive functions regarding operation of the Tricare program.)
If you decide to have the procedure you describe, and if payment of your claim is denied, I believe your only initial option in that case would be to file an appeal of the denial of your claim. Of course, filing an appeal is no guarantee that an adverse determination will be reversed.