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Tricare billing issues...step inside for a jackpot of info!

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#1 DragonFlyer


    Mrs. O'Leary

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Posted 28 September 2009 - 09:34 PM

Have you ever gotten an EOB from Tricare and then...your doctor sends a bill that doesn't match?

Have you ever gotten a collection letter from a CA, and they are adding fees and collection costs to a medical bill?

Did your doctor fail to tell you that your eye exam, valued at $195, isn't covered by your Tricare Standard plan?

Did you know that in addition to regular HIPAA federal laws, that Tricare is also enforceable by additional federal laws?

Did your doctor send you a bill for services you never received?

Did your doctor try to bill you for the balance between what Tricare pays, and what they charged for services? (ie, balance billing)

Did your doctor "forget" to file medical claims until a year later, and Tricare rejected them because they weren't "timely"?

Did your doctor try to tell you that your "waiver" to pay any uncovered costs was sufficient documentation to send your outstanding balance to collections?

Well...step inside here!

Jackpot on Tricare info:

From the "Provider Handbook" via Tricare, found here: http://www.humana-mi...andbook/toc.asp

I am so happy to dig this up. :)

Laws that apply to the military healthcare system: http://www.humana-mi...k/prov-info.asp

In part, it states:

Provisions of the U.S. Constitution authorize Congress to make laws by passing an “Act” (e.g., National Defense Authorization Act for Fiscal Year 2008). When an act is passed by Congress and signed by the president, it becomes a federal law, which generally supersedes any state law (unless it specifies that a state law may apply). An act can be codified in a number of statutes. These statutes are classified and coded in the United States Code. Title 10 of the United States Code houses all statutes regarding the armed forces.

When an act relevant to TRICARE becomes law, the Department of Defense (DoD), through the TRICARE Management Activity (TMA), directs Humana Military Healthcare Services, Inc. (Humana Military) on how to administer that law. This direction comes through modifications to the Code of Federal Regulations (CFR). The TRICARE Operations Manual, TRICARE Reimbursement Manual, and TRICARE Policy Manual are updated continually to reflect changes in the CFR. Depending on the complexity of the law and federal funding, it can take a year or more before direction from DoD is given through TMA and Humana Military can begin administration of the new policy.

AAANNNNNDDD more from this site: http://manuals.tricare.osd.mil/

Authority for the TRICARE Program is the 32 CFR 199. TMA is providing a version of Title 32 to the Code of Federal Regulations, Part 199 (32 CFR 199) as a convenience for the TMA community.

32 CFR 199 (TMA Version), April 2005
10 USC 55 (TMA Version), January 2007

Policy on balance billing. http://www.humana-mi...nce-billing.asp


Balance billing applies only to services covered by TRICARE. TRICARE’s balance-billing limit also applies when other health insurance (OHI) is involved. Providers may not bill beneficiaries for administrative expenses, including collection fees, to collect TRICARE amounts.

In addition to the balance billing being covered under federal laws (above), we also have the "hold harmless policy" at our disposal for non-covered services. From: http://www.humana-mi...nsibilities.asp

It states:
Hold Harmless Policy
A provider may not require payment from a TRICARE beneficiary for any excluded or excludable services the beneficiary received from the network provider (I.e., the beneficiary will be held harmless) except as follows:
  • If the beneficiary did not inform the provider that he or she was a TRICARE beneficiary, the provider may bill the beneficiary for services provided.
  • If the beneficiary was informed that the services were excluded or excludable and he or she agreed in advance to pay for the services, the provider may bill the beneficiary.
Additionally, if Tricare rejects any claims, the provider is expected to accept full financial responsibility of rejected claims: http://www.humana-mi...overed-svcs.asp

ANNNNND....even if they do have any "waiver" on file:

For the beneficiary to be considered fully informed, TRICARE regulations require that:
  • The agreement is documented and signed prior to the specific non-covered services being rendered.
  • The agreement is in writing.
  • The specific treatment, date(s), estimated cost of service, and billed amounts are documented.
General agreements to pay, such as those signed by the beneficiary at any time of admission, are not evidence that the beneficiary knew specific services were excluded or not allowable.

For more information on disputing medical bills, please see our Medical Billing and Medical Collections Forum for the HIPAA Dispute Program, as generously offered by WhyChat.

(disclaimer...this information is provided by a non-attorney. Please seek legal counsel on all information contained herein.)

Edited by DragonFlyer, 28 September 2009 - 09:38 PM.

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