Tough adjustment: Health care providers having trouble with TriCare referrals

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focus_insuranceThree months ago, UnitedHealthcare took over the TriCare contract from TriWest Healthcare Alliance for the 21-state western region.

But after that change took effect April 1, few providers were prepared for what happened next: lack of referrals, slow payments, new billing codes, new requirements and reduced services. In Colorado Springs, Alpine Autism Center says UHC already owes the clinic $120,000 in back payments, and Autism Behavior Associates Inc., another autism care provider, nearly had to close for a month, it said, because payments were late.

“This is going to cause lawsuits,” said Tanja Brown, clinical director of ABA. “They’re changing things with no notice and no reason. Children are going to lose the services that they need.”

Before United took over managing the TriCare services, TriWest had held the contract for more than 16 years. Immediately, there were problems — and those problems have led to low cash flow and fewer patients for TriCare providers in the Colorado Springs area.

First symptoms

The first problems were with referrals for specialty care — which stopped immediately when UHC took over. The referrals from primary care providers are needed for patients to access other care.

In Colorado Springs, common referrals are for physical therapy and for behavioral health care. Without the referrals, patients can’t make appointments or receive care.

“Our patient load dropped instantly,” said Tana Rice, office manager for Alpine Autism Center. “And even when patients started coming back, we weren’t getting paid. We still aren’t. I am hopeful that we will — eventually.”

The lack of patients was a particular problem for Alpine Autism, which estimates that 70 percent of its patients have TriCare as their insurance provider. ABA estimates that about 30 percent of its patient load is covered by TriCare.

Rice enlisted the help of Congressman Doug Lamborn’s office, which she says is working to help resolve the issue.

“It’s a little better now,” she said. “But the way they do business — it went from taking a few hours twice a month for billing to a few days twice a month.”

For its part, UHC says it has improved the process.

“UnitedHealthcare has made real, measurable progress in many aspects of its TriCare West Region operations, working collaboratively and effectively with the TriCare West Region Office and the Military Treatment Facilities,” said spokesman Will Shanley in a statement. “UnitedHealthcare is committed to ensuring TriCare beneficiaries continue to receive timely and necessary access to care. We appreciate the Department of Defense’s guidance and collaboration throughout the waiver period.”

But some providers feel that the more complex system is here to stay. And because of the cash-flow issue, Alpine Autism can’t hire more staff to deal with additional paperwork requirements.

It’s enough to make Brown’s blood boil.

“I’m very vocal about this,” she said. “I’m fighting it. But I’ve heard of at least two providers who are selling their companies and opening offices on the East Coast.”

Why it’s worse here

The problem is exacerbated in Colorado Springs, officials say. Evans Army Community Hospital isn’t equipped to handle specialty services, but is the major military hospital serving Fort Carson as well as Schriever and Peterson Air Force bases. And three years ago, the Air Force Academy downgraded its hospital to an urgent care clinic.

The military uses more civilian providers in Colorado Springs to fill the gaps in the military health care system than in other cities. And some worry that if the problem persists, providers won’t take as many TriCare patients in the future.

That, some fear, could have a noticeable effect on military decisions down the road. Officials speaking on background said that the military often looks at available health care services when deciding where to place troops — or where to remove them. If the Springs can’t provide adequate supplemental care to military families, the result could be fewer troops in the future.

It’s a scenario that could be starting to happen already.

“I’ve had to turn down some TriCare patients,” Brown said. “In the past month, I’ve turned people away. We just can’t afford it.”

It’s not just the specialty clinics that are feeling the pinch. Memorial Hospital, one of the largest TriCare providers west of the Mississippi River, and its parent University of Colorado Hospital in Aurora, are having problems with UHC as well.

“Our military patients and providers have experienced significant problems and delays gaining authorizations for referrals,” said Dan Weaver, spokesman for the hospital system.

“The temporary waiver for authorizations has solved the problem for now, though we fear this could again become a problem once the waiver expires.”

Memorial and University of Colorado Hospital are going to find out soon — after three extensions, the waiver expired last week.

Additional troubles

Both UCHealth hospitals have had other issues, too.

“UCHealth and our providers have also experienced serious inaccuracies and delays in payments, as well as significant difficulties accessing the UnitedHealthcare website and call center, including hold times of up to five hours,” Weaver said. “We hope these issues are corrected immediately … these same problems are being seen almost universally by hospitals and providers since the TriCare contract was awarded to UnitedHealthcare.”

To add insult to injury, the autism clinics received new guidance from UHC, which Brown believes is designed to curb costs by cutting services.

“They are now saying that patients can only be seen for two years,” she said. “And every six months, we have to show exceptional progress.

“For some of these patients, if we are keeping them from retreating, it’s a success. Without our services, they could retreat back to things that cause them physical harm, they could withdraw. It seems these new rules are designed to keep low-performing kids from getting services.”

Rice says she hopes the paperwork situation eases in future months. She credits Lamborn’s office with working to solve the issues in the Springs.

“He’s working to get some military people here, to see what the situation is in the Springs,” she said. “And he’s helped us in other ways as well.”

But the real help needs to come from the Department of Defense, Brown said.

“They need to realize that in order to save money, UHC is harming these families,” she said. “I’m going to make sure they realize it — because I’m not going to be quiet.”

That squeaky-wheel attitude has helped in the past, she said.

ABA has received its reimbursements and payments from United Healthcare much faster than other providers have.

“And that’s because I will drive them crazy,” she said. “I call and call until they pay.”

2 Responses to Tough adjustment: Health care providers having trouble with TriCare referrals

  1. United Heath Care is/was managing Secure Horizon AARP Medicare Advantage Plan and we had the same issues. This has NOTHING to do with ObamaCare

    Mike
    July 16, 2013 at 9:05 pm

  2. UHC is only concerned with making money and not the People or business it should serve. I never got good service from them and then my 87 year old mother was taken Advantage of as well. Shame on them for taking Advantage of the elderly.

    Colorado Springs native
    July 17, 2013 at 12:25 pm