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Claims Hassles Should Fade With TRICARE Fixes

By Douglas J. Gillert
American Forces Press Service

WASHINGTON, April 12, 1999 – Claims problems reported by patients and providers aren't likely to recur after administrative changes on tap for TRICARE take effect.

Most of the problems have occurred in new TRICARE regions, according to Tom Osoba, director of operations in the TRICARE Management Activity's Aurora, Colo., office. Those problems have included confusion over cost shares, deductibles and authorizations for specialty care, he said. Compounding the problem: 15 eligibility categories, plus numerous other special and temporary health categories that qualify people for military health care.

The root cause is a system so complex, it confuses nearly everyone, from patients to physicians to administrators, Osoba said. But TRICARE, which already scores high with enrollees and providers where it's been around for awhile, is about to get simpler everywhere.

"There's quite a bit of action being taken," he said. "We have begun more than a dozen initiatives, including less DoD oversight and more contractor responsibility for the claims process. We've asked the contractors to tell us how they manage their non-DoD, commercial claims. When we see that these business practices work, we will authorize them to institute these best business practices within TRICARE."

Osoba said DoD realizes it can't implement managed health care everywhere, particularly in rural areas underserved by health maintenance organizations. Even so, TRICARE still offers an alternative to more costly medical care, he said. "TRICARE Standard [formerly CHAMPUS] offers the same standard for care as the Blue Cross high option plan offers to federal civilian employees," he said, "and it's available everywhere.

"One problematic issue is third-party liability cases," Osoba said. For the most part, the law has required DoD to "chase and pay" -- that is, find and collect from third-party insurers (private medical insurance carried by beneficiaries) before settling contractor claims. That law was changed to let DoD pay claims first, then go after third-party remuneration.

Some beneficiaries neglect to pay legitimate bills for cost shares and deductibles, because they don't understand their liability, Osoba said. "If you receive a collection agency notice, don't panic but don't ignore the notice," he said. "There's help out there. First, make sure the [health care] services received were program benefits. If the services received were not program benefits, you need to pay the bill."

When legitimate mistakes are made, DoD has several mechanisms for setting the record straight, Osoba said. He said commanders should become involved in assisting their people resolve disputes or improper billing. He said TRICARE can help, offering telephone assistance from Aurora at (303) 676-3526. "It's a busy number, but you can leave a message and we will get back to you," Osoba said. TRICARE beneficiaries can also call their local TRICARE Service Center for help or can contact regional lead agent offices.

Soon, the Military Medical Support Service at Great Lakes Naval Station, Ill., is planning to establish a toll-free telephone service for active duty members needing claims assistance. The service already processes active duty claims for all but three of TRICARE's U.S. regions, although TRICARE contractors will eventually process all claims. Although run by the Navy, the toll-free service will be available to all service members.

Simplifying claims processing will get jump-started June 1 with implementation of the first of four phases, according to Mike Carroll, chief of the office of program requirements in Aurora. Then, TRICARE will implement several changes to "make life easier for clinicians and patients," he said. "We're deliberately shifting the focus from military specification requirements to making the provider and beneficiary satisfied with the process."

Besides allowing contractors to determine the best way to process claims, TRICARE will change the cycle time for claims -- from 75 percent of all claims processed in 21 days to at least 95 percent of all claims without mistakes in 30 days -- the commercial standard. If the claims processor doesn't pay the claim in 30 days, it will be charged interest each day, money that goes back to the provider. "If they aren't as prompt on paying a doctor's claim, he's going to get more money," Carroll said.

This improvement will occur in the second phase and should begin in about six months, Carroll said.

The third phase will deal strictly with mental health issues. A report is due mid-summer from a DoD committee reassessing mental health process requirements. Again, contractors will have a major input to improving those processes, Carroll said.

Phase IV deals with legislative issues and limitations, he said. For example, contractors have suggested they be allowed to collect and retain third party payments. When and if such changes occur is up to Congress, Carroll said.

"This is a huge program change that will encourage providers to join our networks," he said. "It also will better satisfy beneficiaries by removing burdensome requirements, such as reducing the number of incidences where authorization is required before the service is rendered.

"When we move into a new round of contracts, it will take this several steps farther and capitalize on what the industry has learned in terms of speed, accuracy and customer satisfaction," Carroll said. "We want to capitalize on that and give our TRICARE beneficiaries the services they deserve."

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