Examples of Outcome Reporting Bias in Vaccine Studies: Illustrating ...
Tricare To Allow Patients In Tricare West Region To Receive Specialty Care Without Preapproval
The Defense Health Agency has suspended a requirement for Tricare Prime patients in the West Region to get pre-authorization from their Tricare contract manager for specialty care.
Defense Department health program officials announced Monday that the beneficiaries still are required to get a referral before seeking specialty care, but pre-authorization from TriWest Healthcare Alliance, the company that manages the Tricare program in the western U.S., will not be required through March 31.
The process is retroactive to Jan. 1.
Read Next: Video Shows Air Force F-35 Fighter Exploding in Fireball at Eielson Base in Alaska
The waiver announcement is directly tied to problems with TriWest's referral portal that have affected processing, said Jacob Sanchez, referral management subject-matter expert for Tricare at the DHA.
"If you have Tricare Prime and are in the West Region, this waiver will allow you to access specialty services without interruption to your care," Sanchez said in an announcement of the change.
TriWest was awarded the contract to manage the Tricare West Region in late 2022 and began efforts to assume the contract in earnest last February after a federal court ruled it had rightfully won its bid.
Issues with the transition began to emerge in December when participating providers began voicing concerns that they had not received communications from TriWest on joining its network.
Then, customers who were required to update their payment information with TriWest found themselves unable to do so because of troubles with TriWest's online portal and call center.
Patients have written Military.Com saying that they have experienced lost referrals; been referred to the wrong type of doctor -- for example, a brain surgeon when a spine surgeon was needed; and endured delayed or canceled referrals.
"These are not just administrative failures -- they are directly impacting military readiness and the well-being of those who serve," wrote an Air Force airman. "This is a national problem affecting thousands of service members and their families, and yet it seems to be slipping under the radar."
According to the waiver announcement, Tricare Prime enrollees may receive care from any Tricare-authorized specialist if they have a copy of an unexpired referral authorized by Humana Military or Health Net Federal Services before Jan. 1 or a referral dated Jan. 1 through March 31 from their primary care provider; and a copy of the waiver letter, which can be found on the Tricare West Region website.
The announcement also allows Prime patients in the region to see both network and non-network providers, as long as they are authorized by Tricare. They can ask the providers directly whether they are Tricare-authorized.
The waiver does not apply to: inpatient care; applied behavior analysis or other services under Tricare's Autism Care Demonstration; laboratory developed tests; or service under the Extended Care Health Option program.
Those services still will require pre-authorization, according to the announcement.
Tricare officials said that, beginning April 1, beneficiaries who see a non-network provider will start paying point-of-service fees, and they will be required to get preapproval from TriWest for any specialty care they were referred to by their primary care physician.
Related: Problems with Tricare Contract Transition 'Actively Harming' Military, Lawmaker Tells Pentagon
Story ContinuesTricare Lets Patients Bypass TriWest Problems Slowing Specialty Care
This article was updated to include the location of the Tricare West Region referral waiver approval letter.
Amid continuing problems with the transition to a new West Region contractor, Tricare officials have temporarily suspended a rule requiring policyholders to get their referrals to specialists approved — essentially allowing Tricare West Prime beneficiaries to bypass that contractor, TriWest, in order to get specialty care.
The waiver process allows beneficiaries to take their referral from a primary care manager directly to their specialist without waiting for approval from TriWest. Beneficiaries should also take a copy of the Tricare West Region referral waiver approval letter, which can be found at www.Tricare.Mil/west, by scrolling down to the link in the third paragraph. The waiver is in place through March 31 and is retroactive to Jan. 1, the start of the new contract and transition to TriWest Healthcare Alliance in the West region. Beneficiaries and medical providers alike have experienced a number of problems during the transition prompting lawmakers to seek answers.
"TriWest's referrals portal has experienced issues that have affected the processing of new referrals," said Jacob Sanchez, referral management subject matter expert for the Tricare Health Plan at Defense Health Agency, in the announcement of the waiver. "If you have Tricare Prime and are in the West region, this waiver will allow you to access specialty services without interruption to your care."
Beneficiaries must still get referrals from their primary care manager. In addition, TriWest will accept all referrals and authorizations approved by the previous contractor — Health Net Federal Services or Humana Military — that are dated before Jan. 1. TriWest will accept those until the referral expires or until June 30, whichever comes first.
Meanwhile, some beneficiaries have told Military Times their specialists can't get access to their approvals in the TriWest system. Information was not immediately available about what action beneficiaries should take if their referrals dated before Jan. 1 were lost in the system. Some are being told to go back to that primary care manager for another referral.
"This specialty care referral waiver is really just a partial fix. It fixes things for those with a primary care manager" who can get an appointment with that PCM, said Karen Ruedisueli, director of government relations for health affairs for the nonprofit Military Officers Association of America. "But if you're someone in the West region who lost your primary care manager as a result of this transition and you've been assigned somebody new and can't get a new patient appointment for the next seven weeks ... It doesn't really help you if you don't have access to a PCM."
This waiver allows people to see non-network providers, Ruedisueli said. It also allows TriWest more time to build up their network of medical providers, and it gives beneficiaries until April to find another provider if needed.
With the new contract, six states were moved to West region coverage from the East region, bringing the total to 26 states. Here's what Tricare beneficiaries in the West need to know about the temporary suspension of the requirement for TriWest to approve referrals, according to officials:
There are some exclusions to the waiver, such as Applied Behavior Analysis and Autism Care Demonstration, as well as Extended Care Health Option services, which affects those who depend on home health services for medically fragile children.
"It's interesting that they purposely excluded a very disabled portion of the military community," said Dr. Kristi Cabiao, CEO and president of Mission Alpha Advocacy, an organization that works to improve quality of life for military families within the Exceptional Family Member Program.
The waiver also excludes inpatient care and laboratory developed tests.
The broad issues surrounding the recent Tricare contract changes include problems with payments, authorizations and referrals and errors in provider and beneficiary information, Cabiao said.
Families have reached out to Military Times about a plethora of issues with TriWest, which are exacerbated by ongoing problems with reaching the contractor through their web portal or call center.
Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book "A Battle Plan for Supporting Military Families." She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.
Share:
Tricare West Region Beneficiaries Get Another Chance To Update Payment Information
Tricare beneficiaries in the West Region have been given another extension for the deadline to update their payment information with new regional contractor TriWest.
The Defense Health Agency announced Tuesday that beneficiaries who are enrolled in Tricare Prime and Tricare Select, as well as programs that include Tricare Young Adult, Tricare Reserve Select and Tricare Retire Reserve, now have until Feb. 28 to update their payment information.
The original deadline for those who pay for Tricare with a bank electronic funds transfer, credit card or debit card was Dec. 31, 2024. As a result of problems with TriWest's online portal and phone system, the deadline was extended to Jan. 15 for those on Tricare Young Adult and Tricare Reserve plans and Jan. 31 for beneficiaries on the Prime or Select programs.
Read Next: He Met Trump After Being Booted from the Space Force. Then, He Was Tapped to Help Lead the Air Force.
Should beneficiaries not update their payment methods, they will be disenrolled from Tricare retroactive to Jan. 1.
"While the deadline has been extended, you shouldn't wait to take action," Malcolm Jones, an enrollment specialist for Tricare at the Defense Health Agency, said in a statement. "To keep your coverage, use the TriWest secure portal, mail in the payment request form, or call them to set up your payments."
Those who pay for their health program by military allotment do not have to update their information; the requirement also doesn't apply to active-duty members and their families or those who use Tricare for Life or the U.S. Family Health Plan.
According to TriWest, 70% of those who needed to update their payment information had done so by the second week of January.
TriWest has encouraged beneficiaries to enroll online, but many patients and providers have reported difficulties with TriWest's website, and when they try to call in their payment information, have faced hourslong wait times to reach a person who can help them.
The spouse of a retired Marine Corps officer told Military.Com she waited more than three hours on three separate occasions to speak to someone about her information and referrals.
She waited on hold, only to not have her questions answered because none of her medical information was available to the call center staff, she added.
"While polite, the TriWest phone answerers seem completely incompetent," she said.
TriWest was awarded the new Tricare contract, which took effect Jan. 1, in December 2022.
The change affects 4.5 million Tricare beneficiaries, including nearly all beneficiaries in six states including Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin that shifted to the West Region, as well as several unique ZIP codes in some locations.
In a statement to Military.Com, TriWest officials said the Defense Health Agency and TriWest have made "every effort to notify beneficiaries with pending deadlines to update their recurring payment information."
"This sense of urgency has generated a higher volume of calls to the call center for payments. TriWest is closely monitoring its customer service lines and has implemented a plan to adjust staffing levels quickly to address increases in call volumes. As a result, call hold times are being addressed, and we continue to see them decrease each day," the company said in an emailed statement.
Related: Tricare West Region Beneficiaries and Providers Are Flooding Former Contractor with Calls
Story Continues
Comments
Post a Comment