Important tricare information

[clayverde 2]

Okay, this is going to be a long post - I'm warning you now!! :thumbup:

But it is really important and I really think I should pass it on, so here goes...

I live in Minneapolis MN, so I am part of Triwest, but I have Tricare Prime Remote. I have already had my lapband surgery (love it!! best decision ever!:w00t:) and the whole process with Tricare has been great. I had no problems with approval, fills, etc.

Recently I got a bill from Park Nicollet (the clinic where I am seen and is affiliated with the hospital where I had the surgery) for my nutritionist appointment. It cost about $130. It said that the claim had been filed with Tricare and was denied, so it was now the patient responsibility.

I went back and looked at the Explanation of Benefits that I got in the mail (BTW - NEVER throw those things out. Keep them!! They are critical for circumstances like these!!) for that appointment and it showed that they had indeed denied payment of the bill, however it also showed that the patient responsibility was *0*. It also stated “This service is non-covered. Network providers may not charge beneficiaries for the services under the hold harmless provisions of their network providers. Providers are eligible for an allowable charge review. Please note that the 90 day appeal period begins with the initial denial of the claim.” So it seemed pretty clear that I don't have to pay for the appointment, regardless of the denial.

I call Tricare and ask what was going on. I was told that I AM responsible for the bill. That if I think Tricare should have paid for it, then I can file an appeal and I have 90 days, etc. So she gives me a bunch of info and we hang up. I begin to do research on how to appeal and how to prove that the nutritional appointment was medically necessary. I end up having a question and call Tricare back a few days later for clarification.

This time, the lady I speak with is very clear - I do NOT owe that money. She explains that first of all, the explanation of benefits is pretty much the law - if it says you don't owe anything, you don't owe it. She said that the clinic and hospital has a contract with Tricare. Part of that contract is to accept a certain amount for services and waive the balance (so you often see that Tricare paid one amount even though the doctor charged more, but you don't owe the difference). The other part is to accept what Tricare covers for services - I don't know if this is part of the remote deal, because I don't have a choice of going to a military clinic or hospital. I have to go to a civilian hospital. But it might not be - it might just be a normal part of the Tricare contract. That for them to be able to accept Tricare insurance, they have to accept that they may provide services that Tricare simply doesn't cover and they can't turn around and bill the patient. Regardless, I am not responsible for the cost. She tells me to call the billing office and basically, nicely tell them to review their contract and the copy of the explanation of benefits that they received (apparently when you get one, they get their own copy) and notice that my responsibility is $0. She said that should clear it up and I'd be good.

I called the billing and basically they told me that the doctor doesn't provide charity nutritional appointments and of course the bill had to be paid - either by me or my insurance, but it didn't just get dismissed. I called Tricare back and spoke with someone new, who said that same thing as the last lady - that I did not owe the money and she would be happy to talk to the billing office. The three of us had a phone conference and the clinic agreed to investigate the bill and let me know of the decision. We hung up with them and the Tricare lady let me know that this might be an issue because they didn't deal with Tricare that often, but she was sure that the manager or someone further up the food chain would look into it and realize they were violating their contract with Tricare simply by sending me the bill. She said once they realized that, they would probably let me know it was taken care of.

(can you guess where this is going??:w00t:) I get another bill from the clinic that says they did an investigation and determined that they provided services and I accepted them, so I should pay. They also send me a copy of a paper that I had signed at the time, stating that "Medicare may not cover this appointment. Should they deny payment of this appointment, you will be responsible for it, etc." [Okay, side note here, why did I sign that?? Because I don't have Medicare! Because it was obviously a form that they had every single patient sign and I figured, well, I don't have Medicare, so it doesn't matter AND I have Tricare Prime, so I know I'm good - I don't have copays, etc.]

I call Tricare and basically ask, WTF?? The lady I speak to there tells me that I owe the money. That if I want to appeal, here is the info to appeal. AARGH!! :thumbup:

After cursing some more, my hubby convinces me to calm down and call Tricare again. I do and this time I talk to a guy who is great! He explains to me that I am absolutely, 100% NOT responsible for the bill. He says that if the clinic wanted the bill paid, they should have appealed the denial and proved that it was medically necessary. He said that almost always if they appeal it (for that specific appointment for lapband patients) it will get approved. He said that right now, Tricare doesn't have the nutritional appointments already covered as part of the lapband surgery process, but the surgery coverage is still new and they are in the process of figuring out what is necessary and what isn't etc. He said this is part of the normal growing pains of adding a new surgery to their coverage. But the responsibility of appealing is on the clinic NOT me. He explains further that not only does it not matter that I signed that form about the Medicare (because I don't have Medicare), even if it had specifically said Tricare, it wouldn't matter because as part of their contract with Tricare, they specifically state that the clinic can NOT allow a patient to sign away their rights. He said they should know better than to try and have me sign it anyway. But again, he thinks it has more to do with their lack of knowledge of Tricare than a deliberate attempt to trick me into paying the bill.

So he goes over it all with me and we talk to the clinic AGAIN, and basically, we get told the same thing. Pay us the money. Plus, the manager says that she talked to Tricare and they agreed that I was responsible for the bill. We hung up with them and that is when the Tricare guy told me to file a fraud complaint. He explained that the clinic had more than enough chances to read their contract with Tricare and figure out that I was not responsible for the bill. He said at this point, he had to assume that they were trying to commit fraud. So I wrote a letter with all the information, added copies of the bills, etc and sent it all to the Tricare Fraud department.

Eventually I got a call from a guy at the Fraud department who said that he is working with the clinic and explaining to them in no uncertain terms that I do no owe the money and the possible repercussions of them pursuing the bill. He said that they are breaking not one but TWO federal laws by attempting to have me sign away my rights and by sending me the bill they knew I didn't owe. He said that they were in danger of 1. nullifying their contract with Tricare, which would not only mean they can't accept Tricare as insurance anymore but they wouldn't ever be able to and 2. begin a federal fraud investigation into their billing practices. He said that if there continued to be a problem, he would contact me to let me know.

Needless to say, I have not gotten another bill from Park Nicollet and I have not heard anything more from either the clinic or Tricare or Tricare Fraud.

So the moral of this very long story is:

You can't sign away your rights

Don't sign them away anyway, it just makes things more confusing.

You probably don't owe that copay or that nutritionist bill

Even if you call Tricare, don't assume they have given you the right information!!

I think it is ridiculous that I can call Tricare and keep getting the wrong information. But the point is, that the information you are getting might be wrong. Keep calling, keep notes on every single time you call and who you talk to you (that saved my butt this time because when I was told again from Tricare that I owed the money and I was responsible for the appeal, I was able to say, I talked to Diane on 10/13 and she said I wasn't. Which forced her to go and read the notes on the file and realize she was wrong!! She didn't apologize or anything, but she did put me on hold, talk to a manager, and come back with the correct info and told me that I was correct, I did not owe the money!)

Good Luck and I hope this info helps!! :thumbup: