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.
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.
Will surgeries on pre-existing scar be covered?
November 8th, 2009 | TriCare Help | Posted by Military Times
Q. My young daughter was burned two years ago. She has had surgery two times for scar revision as she has grown, and will need at least two more operations as she gets older.
My family and I will get Tricare later this year when I am 60. Will my daughter’s subsequent surgeries be covered by Tricare, or will coverage be denied or limited because the scar is a pre-existing condition?
Tricare is not an insurance company; it is a federal health benefits program, similar in that respect to Medicare. Unlike many commercial health insurance plans, Tricare has no restrictions or limitations on the coverage of pre-existing conditions.
A potential problem, easily overcome, could be with the continuity of care if you want the later surgeries performed by the same surgeon who did the previous operations.
For Tricare to cover the surgery, the surgeon must be or become a Tricare-authorized provider. That is, he must apply to Tricare and submit the information required to establish that he is a properly trained and licensed physician in the state where he practices.
When Tricare approves his application, he will be authorized to receive payment for services rendered to Tricare beneficiaries. All insurance plans and companies require some form of provider authorization.
Apart from certain medical emergencies, Tricare may not pay for any services received from an unauthorized provider.
What if my doctor says he takes Medicare, but not Tricare?
September 11th, 2009 | TriCare Help | Posted by Military Times
Q. I have Tricare For Life. If I go to a doctor who accepts Medicare but does not accept Tricare is that something that I need to be concerned about? I understand that Medicare will automatically forward a claim to Tricare.
The only thing the doctor cares about is whether he gets all the money that is due to him.
Here’s the way it works. This is all explained in your Tricare for Life Handbook. Call your Tricare Service Center and ask for a free TFL Handbook, or download one here.
As a Tricare for Life beneficiary, you know that you have complete coverage by Medicare Part A and Part B plus complete coverage by Tricare Standard. You know, also, that you must seek all your civilian medical care from Medicare providers.
The doctor will submit a Medicare claim for the services he provides to you. Medicare will process the claim and pay its share to the doctor directly. That will usually be 80 percent of the amount the doctor billed on the claim unless there is a Medicare deductible involved. If there is a deductible, Medicare will subtract it from the amount it approves and pay the doctor 80 percent of the remainder.
Then it will forward the claim to Tricare automatically. Tricare will process the claim and for every service on the Medicare claim that is also covered by Tricare, Tricare will pay the doctor whatever Medicare did not pay for those items. That will usually be your Medicare copayment and your Medicare deductible if applicable on that particular Medicare claim.
On the vast majority of your Medicare claims, both Medicare and Tricare will cover all the services you received. When that happens, which is almost always, Tricare will pay whatever Medicare did not pay, up to the amount Medicare approved. That payment by Tricare will complete payment of the Medicare claim and the doctor’s bill. Both you and the doctor will be happy. He doesn’t care where the money comes from as long as he gets it.
Now the bad news. Sometimes you get a particular medical service from a Medicare doctor that Medicare does not cover, but Tricare does. Medicare will deny payment for that particular item and forward the claim to Tricare with that item unpaid. Tricare will be your only “insurance” for that particular item. As Medicare paid nothing, and because Tricare is your only health insurance for that item, all Tricare claims processing rules must be applied (by law) when it processes the claim for that item which Medicare did not cover. That means when Tricare processes the charge for that item, it must (by law) apply your Tricare deductible and 25 percent cost share to the amount Tricare allows for that item. On that claim, you may have to pay some of the cost of that item Medicare did not cover.