How can TFL refuse to pay for a test doctor ordered?
April 28th, 2011 | TriCare Help | Posted by Military Times
Q. I am a retired Air Force officer and have Medicare parts A and B and Tricare for Life. Recently my wife’s doctor ordered a set of lab tests that included a thyroid function test; neither Medicare nor TFL would pay for this test, leaving us to pay for that out of pocket (all other billed items were covered by one or both). How can Medicare and Tricare deny that tests ordered by a physician are “necessary”? And why was the $100 out-of-pocket payment we had to make not credited against our Individual/Family Deductible amounts?
You have the answer to your first question in your hands. Anytime a Medicare or a Tricare claim is denied, the reason for the denial is always reported on the Explanation of Benefits.
Every time Medicare or Tricare processes a claim, it sends the beneficiary and the participating provider a report of the details of all its actions when it processed the claim. That document is called an Explanation of Benefits, or EOB, for short.
The EOB reports the amount the provider billed, the amount the insurance plan approved or allowed (those terms mean the same thing), the amount the plan paid, and to whom it was paid.
If the claim, or a portion of the claim was denied (nothing was allowed or paid for that medical service), the EOB also contains a statement that tells you exactly the reason for the denial. If you have questions about the claim, including the denial, the EOB has a toll-free number you can call for a full explanation of the reason and, if possible, what you need to do so the claim becomes payable. Additionally, the EOB describes the things you must do to file an appeal. An appeal requires the plan to reconsider the way it processed the claim to ensure that all the rules for payment were considered correctly.
As I do not have a copy of the two EOBs, I have no way to know why the claims were denied. But since a test for thyroid function is a covered service under both Medicare and Tricare, the fact that the claims were denied makes me believe there was a error of some kind in the way you got the medical service or in the way the doctor filed the claim.
Was the doctor who ordered the tests a Medicare provider? A medicare provider is one that is enrolled with the Medicare program and us authorized to file Medicare claims for services provided to Medicare beneficiaries. If you have TFL and get care from a non-Medicare provider, neither Medicare nor Tricare may pay the claim.
Unless the EOB states that the amount Medicare or Tricare would have paid was credited to your deductible, the denial of the claim was not related to the deductible. It was denied for some other reason (which is reported on the EOB). The denial of a charge is unrelated to the deductible.
Doctor says she will stop taking Medicare – and Tricare
March 18th, 2011 | TriCare Help | Posted by Military Times
Q. My wife is 60 and enrolled in Tricare Prime. Her doctor has recently notified her that she will soon stop seeing Medicare patients, and since the law requires that if she accepts Tricare she must also accept Medicare, she will also stop seeing her Tricare patients. One option is to find another doctor in the Prime network. My wife prefers to stay with her doctor, who offered the option of continuing to see her if we pay her out of pocket for her services. Can we switch to Tricare Standard, pay out of pocket, and file for reimbursement from Standard without invoking the link between Tricare and Medicare? Would the doctor be limited by Tricare billing/reimbursement limits? Or would we be denied Tricare reimbursement because the doctor wants nothing to do with Medicare?
I believe your wife’s doctor is confused about the requirements of law regarding Medicare and Tricare participation. I believe the law she is thinking of is the one that requires hospitals that accept Medicare patients to also accept Tricare patients. If we are talking about the same law, note that it applies only to hospitals. It does not apply to individual providers such as physicians. To the best of my knowledge, there is no requirement for Tricare Authorized Providers to accept Medicare patients.
There is a rule that physicians must be registered with Tricare as authorized providers. If you get medical care from a doctor who is not authorized by Tricare, Tricare cannot pay for his or her services.
It is very important for your wife’s doctor to write very soon to the Tricare Headquarters so she can get the correct information officially and learn exactly and officially where she stands. The address is Tricare Management Activity, 16401 E. Centretech Parkway. Aurora, CP 80011-9043. That office manages the Tricare Program worldwide. It is a federal agency and part of the Office of the Assistant Secretary of Defense for Health Affairs.
Just in case your doctor doesn’t want to write, then you should do it. Tell Tricare what your doctor believes and get an official answer.
Does my doctor have to accept TFL payments?
February 16th, 2011 | TriCare Help | Posted by Military Times
Q. If a doctor accepts Medicare payments, does he also have to accept Tricare for Life payments?
If you are a Tricare for Life beneficiary, Medicare makes its payment directly to the provider of care. Then, it automatically forwards the claim to Tricare, which is your free Medicare supplement. Tricare processes the claim using Medicare’s EOB for information about what Medicare paid. For every medical service on the Medicare claim that is covered also by Tricare, Tricare pays directly to the provider whatever Medicare did not pay, up to the amount you owe. As that is an automatic action, the Medicare claim and the provider’s bill are paid in full. As the doctor is paid in full by the automatic combined Medicare plus Tricare payments, it is not necessary for him to “accept” Tricare. He still gets paid in full, and you owe nothing.
Your Tricare EOB will prove that the bill was paid in full. Save it as proof if there is ever a question.
When you’ve already paid Medicare’s copay
January 25th, 2011 | TriCare Help | Posted by Military Times
Q. I had cataract surgery in both eyes. I have Tricare for Life, and the eyeglasses are covered under Medicare and Tricare. The eye care provider accepts Medicare and I had to pay the 20 percent copay. What happens when Tricare pays? Does the provider keep both payments? Who returns my copay?
As both Medicare and Tricare cover one set of eyeglasses following intraocular lens implant surgery, Tricare will pay the provider whatever Medicare did not pay. It usually takes a couple of weeks for Tricare to pay the provider what Medicare did not pay.
Contact the eyeglass provider for a refund. Tricare will send both you and the eyeglasses provider an EOB as proof of payment.
My doctor says he doesn’t take TFL – can he do that?
June 22nd, 2010 | TriCare Help | Posted by Military Times
Q. I am retired Navy and my wife and I have Tricare for Life. She was referred to a health care provider for shoulder problems, and the provider informed her they accept Medicare payments but not Tricare for Life payments. Is this against federal law?
You have in mind a rule that applies only to institutional providers, such as hospitals. That rule says that a hospital that accepts Medicare patients is required by law to accept Tricare patients also.
That rule does not apply to individual professional providers, such as physicians.
The way health insurance policies are set up, the patient is always responsible for whatever the primary plan does not pay. That is usually the plan’s deductible and copayment, but it could include other things as well, such as a medical service the primary plan does not cover.
Many Medicare beneficiaries have a Medicare supplement. There must be a hundred or more plans to choose from. In the case of TFL, that choice is made for you — it is automatically Tricare Standard. That was set up in 2001 when Congress created Tricare for Life.
The provider’s only interest is in receiving the full amount Medicare approves as payment for his services on the Medicare claim. TFL is set up in a way so that happens.
If both Medicare and Tricare cover all the services on the Medicare claim, Tricare Standard will pay the provider whatever Medicare did not pay, up to the amount Medicare approved. The Tricare deductible and cost share are waived on those claims. The vast majority of claims filed under TFL are of that kind.
For information about the details of TFL operation, I suggest that you contact your Regional Tricare Service Center and request a free Tricare for Life Handbook, or download one for free, here.
Is my doctor taking advantage of Tricare?
March 23rd, 2010 | TriCare Help | Posted by Military Times
Q. My wife and I feel that our doctor is taking advantage of Tricare by scheduling us for unnecessary appointments and services. Is there an organization such as the Better Business Bureau for doctors that I should contact?
Billing Tricare for excessive and unnecessary services is called abuse and is illegal. Tricare takes such matters very seriously.
I suggest you write a letter to the Tricare office that processes your claims. The address is on your explanation of benefits forms. In your letter, provide as many examples and other details as possible, including names and dates. If other providers are involved — as in a case of excessive laboratory tests —include their names, as well.
Also include copies of any pertinent documents relating to your complaint. Because of provisions of the Privacy Act, both you and your wife should sign the letter. Don’t forget to include a daytime phone number.
Why does my doctor keep billing me?
January 25th, 2010 | TriCare Help | Posted by Military Times
Q. My doctor charged $268. Tricare allowed $192.50 and sent me a check for 75 percent, or $144.38. I paid the doctor $192.50 plus the 15 percent surcharge, for a total of $221.38. Now the doctor is demanding another $46.62, making the total the amount of his original bill, and says he’ll turn my account over to a collection agency if I don’t pay. It’s my understanding that federal law doesn’t allow him to do that. What should I do?
You are correct. The doctor may not charge you more than 15 percent over the amount Tricare allowed. If he sees Medicare patients, he is aware that the Limiting Charge law applies to Medicare claims; he needs to learn that it applies to Tricare claims also.
You should send a report to the Tricare office that processed your claim. The address is on the Tricare Explanation of Benefits form. Include a copy of the EOB and any “balance due” notices from the doctor. If the doctor persists, report him again.
It is unfortunate that the law will not allow Tricare to do more than write to the doctor and explain the federal law. Beyond that, all it can do is threaten to discontinue his status as a Tricare-authorized provider and threaten to cancel his ability to participate in other federal programs such as Medicare.
The doctor may be unaware of what his billing clerk is doing. You might consider writing or talking with him about it.
Who is required to accept Tricare?
January 22nd, 2010 | TriCare Help | Posted by Military Times
Q. Our doctor joined a group practice. Although he continues to see Medicare patients, the office manager said the practice does not belong to Tricare, and we have to pay full price for our medical care and file with Tricare ourselves.
Didn’t you write that if a provider accepts and bills Medicare, federal law requires him to also accept and bill Tricare? What are the facts?
That law applies only to institutional providers, such as hospitals. Individual providers, such as physicians, psychologists, private physical therapists and the like, are not bound by that law.
If the physician has severed his relationship with Tricare and is no longer a Tricare-authorized provider, Tricare cannot pay for any of his services regardless of who files the claim.
If he remains a Tricare-authorized provider but no longer participates in Tricare on the claims, you may use his services and file the claims yourself. In that case, he is no longer required to accept the amount Tricare allows as full payment for his services.
However, there is a law that limits the amount you may be charged for his services. It is a provision of the law governing Medicare called the Limiting Charge. In 1983, Congress made that law apply to Tricare as well as to Medicare.
The Limiting Charge allows a nonparticipating physician to charge a Medicare or a Tricare beneficiary up to, but not more than, 15 percent over the amount Tricare allows on a claim. Tricare will pay its usual amount directly to you. You will be responsible for paying the physician the amount Tricare allowed on the claim plus an additional 15 percent more than the amount allowed.
Your out-of-pocket expense for using such a physician, then, is your usual 25 percent cost share plus the 15 percent surcharge.
You might want to tell the office manager that Medicare and Tricare are required by law to use the same methodology and most of the same databases to calculate the amounts they allow on claims.
The amounts allowed by the two programs seldom differ by more than a few dollars. Tricare often allows slightly more than Medicare because of its younger, healthier beneficiary population.
What’s covered for jaw disorder?
December 14th, 2009 | TriCare Help | Posted by Military Times
Q. We have Tricare Standard. I have been looking through our handbook and cannot find anything on coverage or exclusion of Temporomandibular Joint Disorder, or TMJ. I suffer from this and need to know if Tricare covers any kind of surgery or therapy.
I checked with Health Affairs, and they told me that the only service covered for TMJ problems is oral surgery under certain specific conditions. Health Affairs advises that you or the provider should contact your Regional Tricare Service Center for advice and for information about the procedures that must be followed prior to any surgery.
My opinion is that it might be best if your provider made the call to Tricare in case there are technical or medical questions that he can address best.
Don’t go forward on any treatment procedure without contacting Tricare first.
Our doctor says he no longer belongs to Tricare
November 27th, 2009 | TriCare Help | Posted by Military Times
Q. Our doctor joined a group practice. Although he continues to see Medicare patients, the office manager said the practice does not belong to Tricare, and we have to pay full price for our medical care and file with Tricare ourselves.
I thought that if a provider accepts and bills Medicare, federal law requires him to also accept and bill Tricare. What are the facts?
That law applies only to institutional providers, such as hospitals. Individual providers, such as physicians, psychologists, private physical therapists and the like, are not bound by that law.
If the physician has severed his relationship with Tricare and is no longer a Tricare-authorized provider, Tricare cannot pay for any of his services regardless of who files the claim.
If he remains a Tricare-authorized provider but no longer participates in Tricare on the claims, you may use his services and file the claims yourself. In that case, he is no longer required to accept the amount Tricare allows as full payment for his services.
However, there is a law that limits the amount you may be charged for his services. It is a provision of the law governing Medicare called the Limiting Charge. In 1983, Congress made that law apply to Tricare as well as to Medicare.
The Limiting Charge allows a nonparticipating physician to charge a Medicare or a Tricare beneficiary up to, but not more than, 15 percent over the amount Tricare allows on a claim. Tricare will pay its usual amount directly to you. You will be responsible for paying the physician the amount Tricare allowed on the claim plus an additional 15 percent more than the amount allowed.
Your out-of-pocket expense for using such a physician, then, is your usual 25 percent cost share plus the 15 percent surcharge.
You might want to tell the office manager that Medicare and Tricare are required by law to use the same methodology and most of the same databases to calculate the amounts they allow on claims.
The amounts allowed by the two programs seldom differ by more than a few dollars. Tricare often allows slightly more than Medicare because of its younger, healthier beneficiary population.