Standard, Prime: Weighing the options
April 1st, 2010 | TriCare Help | Posted by Military Times
Q. I am retired from the military and the civil service and am 70 years old. When I became 65, I suspended my civilian health insurance (Blue Cross), enrolled in Medicare Part B and am now covered by Medicare Parts A and B and Tricare for Life. My wife is 58 and is working for the state as a teacher and is provided a health care plan (without charge) and has Tricare Standard. She is allowed to see any doctor of her choosing. When she retires in June 2011, she will have the option of continuing her state Blue Cross plan, but it will no longer be free. Is there a Tricare plan that she can qualify for that will allow her to continue to see the doctor of her choosing?
Tricare is not an insurance policy or insurance company. It is a federal health benefits plan similar to Medicare in that respect.
All insurers require providers to apply to become certified by the plan by proving they are properly trained, educated, and licensed to provide certain medical services. Tricare is no exception.
Under Tricare, your wife’s ability to use any physician of her choice depends on the provider. She may use any provider who has applied with Tricare, been accepted and, thus, has become a Tricare-authorized provider. Tricare may not pay for the services of any unauthorized provider except in certain bona fide medical emergencies.
There will be two possible Tricare plans for your wife: Tricare Standard and Tricare Prime. Prime is not available everywhere. You will have to ask your Regional Tricare Service Center whether Prime is available in your area.
Tricare Standard is a fee-for-service plan. You receive medical care, get a bill, and file a Tricare claim for reimbursement of a portion of the cost. After satisfaction of the $150 Tricare fiscal year deductible, Tricare Standard pays 75 or 80 percent of the amount it allows on each claim. The copayment (cost share - the patient’s share) for active-duty family members is 20 percent of the amount Tricare allows; for all others it is 25 percent of the amount allowed.
On each Tricare Standard claim filed, the provider has the option to participate or not to participate in Tricare on that claim. If the provider agrees to participate, he will file the claim on the patient’s behalf. He will sign a legally binding agreement to accept the amount Tricare allows on that claim as his full payment for the services on that claim. Tricare will pay its share directly to the provider and send an EOB to the provider and to the patient which describes in detail all its actions on those charges. After Tricare has paid its share of the amount allowed, the patient is responsible for paying the provider the difference between the amount actually paid by Tricare and the amount Tricare allowed on those charges. When the patient has done that, the claim and the provider’s bill will have been paid in full. The patient is not responsible for any amount greater than the amount Tricare allowed on the claim.
If the provider chooses not to participate on a claim, a portion of the law governing Medicare applies also to Tricare Standard claims. It is called the Limiting Charge provision. All Medicare providers know of the law, but many are not aware that it applies also to Tricare beneficiaries claims. It limits the amount the patient may be charged to 15 percent more than the amount Tricare allows on that particular non-participating claim. Tricare can pay no part of that 15 percent surcharge. The patient is responsible for that amount in addition to any deductible required and the co-payment (20 or 25 percent of the amount allowed).
Tricare Standard can be used worldwide and is free. A Tricare supplement is strongly recommended for Tricare Standard members in order to pay the deductible and co-payments (called cost shares) and the surcharge on non-participating claims. Read the fine print carefully before buying any Tricare supplement. Make sure you are buying what you think you are buying, and that it meets your anticipated needs.
Tricare Prime functions as a Health Maintenance Organization (HMO). As noted, it is not available in all areas. Certain providers contract voluntarily with Tricare to provide services to Prime members at reduced rates. They have independently negotiated with Tricare and agreed to those amounts. The patient may use only those (Prime) providers. The providers will file the claims on the patient’s behalf and will receive their payment directly from Tricare. The patient is required to pay the provider a fixed amount for each office visit or other medical service. Tricare pays the remainder of the fee directly to the provider. The member may use only Prime providers in their residential area. To use a Prime provider in another area, such as when traveling, special preauthorization from the Prime administrative office is required except in bona fide emergency situations. Prime costs $230 per person, $460 maximum per family, per year.
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.
‘Authorized’ providers, ‘participating’ providers, and the 15 percent
November 6th, 2009 | TriCare Help | Posted by Military Times
Q. One of your recent columns implies that there is a difference between a Tricare-authorized provider and a Tricare-participating provider. I thought they meant the same thing. What is the difference, if any? What does the “15 percent” refer to?
A provider is any person or organization that provides services to another person or organization. Your phone company, for example, is a provider of telephone services.
There are many kinds of providers of health services. In addition to physicians and hospitals, they include self-employed nurse practitioners, physical and occupational therapists, nurses in private practice, clinical psychologists, medical supply and equipment vendors, and the like.
This discussion is limited to physicians. The participation rules apply to all Tricare-authorized providers.
For the safety of their beneficiaries and to prevent (or at least discourage) fraud, all health insurance companies require some form of provider registration or certification. Before they pay claims on behalf of beneficiaries, insurance companies must be certain that providers are fully qualified, licensed physicians in good standing in the states where they practice.
Tricare is no different. To become Tricare-authorized providers, physicians or other providers of health services must apply to Tricare, submit information to confirm their qualifications and be approved. They then can receive payment from Tricare for covered medical services provided to Tricare beneficiaries.
Except in certain medical emergencies, Tricare will not pay for any service a beneficiary receives from an unauthorized provider.
On every Tricare claim, an authorized provider can choose whether to participate. Tricare will allow, and pay, the same amount regardless of whether the provider participates. However, the beneficiary will be responsible for paying more when the provider does not participate.
If providers choose to participate on a claim, they will sign the participation agreement on the claim forms and file the claims on behalf of the beneficiaries. They agree to accept the amount Tricare allows on that claim as full payment for those services.
Tricare will pay its share directly to the participating providers. When the beneficiaries pay their part of the claim, the participating providers’ bills for the covered services will be paid in full.
A beneficiary is not responsible for paying more than the amount allowed for covered services on a participating claim, regardless of the amount billed.
If a provider chooses not to participate on a claim, Tricare will send its payment to the beneficiary, who is responsible for paying the nonparticipating provider as much as, but not more than, 15 percent over the amount allowed on the claim. Tricare will pay nothing toward that 15 percent surcharge.
It’s important to note the difference between the amount Tricare allows on a claim and the amount it pays. On most claims, that difference is the beneficiary’s deductible, if applicable, and cost share. If Tricare denies a charge, however, the amount the beneficiary is expected to pay may be more than those items.
When a Tricare claim, or a portion of a claim, is denied — it will say “$0.00” in the “Amount Allowed” column on the explanation of benefits — the beneficiary should file a written appeal within 90 days. The EOB always reports the reason a charge was denied. An appeal may change, or even remove, the amount a beneficiary is required to pay on denied charges.
Appeal instructions are on the back of every EOB. You cannot appeal by telephone. For further information about appeals, call your Tricare Service Center.
The federal law that limits the amount a Tricare beneficiary may be charged for covered services on a nonparticipating claim is a provision of Medicare law called the Limiting Charge. Physicians who see Medicare patients know about that law. Congress extended the law to include Tricare claims in 1993.
Regardless of whether a provider participates on a claim, if he demands payment in excess of the amount permitted by law, you should notify the Tricare claims processor immediately by mail. Include a copy of the original Tricare EOB and copies of the bills or letters that cite the balance due.