Wiki TRICARE secondary Insurance

[Rbanskikum]

Background: I work for a small ABA company. I'm slowly taking over the third-party billing company. They currently are still billing for us.

We currently have a client with TRICARE as secondary insurance. When we first accepted the client, I was told to inform the client we do not accept TRICARE due to past issues. The family signed a form informing them that they are responsible for the outstanding balance. The family wanted to continue services with us. Family went to submit claims to TRICARE. We are still in-network with TRICARE and we need to submit the claims for them. With ABA we need a pre-AUTH in-order to submit claims. TRICARE will not back date an auth. The billing company does not want to bill TRICARE because they know it will be denied. And they informed us we can not bill the family. From my understanding, we can not. My boss still wants to bill the family since they signed a form in the intake packet. I do not feel comfortable billing the family the outstanding balance until I know for sure we can bill them. Please help me understand if I can bill the family or how can I explain this to my boss. I'm just starting my career and do not want to start out with a mark to my name.

Thank you

 

[thomas7331]

You are correct in being uncomfortable with this. If the provider is in-network with TRICARE, then they're under obligation to file the patient's claims to TRICARE (for example, see: https://www.tricare.mil/FindDoctor/AllProviderDirectories/Network). The contract should state this, and it will also be in your TRICARE region's provider manual which you should be able to find on their web site.

If the patient decides they don't want the provider to file and instructs the provider to not file, that is their right, but in this case the provider is refusing to file the claim because they don't like the terms of the plan. Regardless of whether or not the patient is signing a waiver, this is still most likely a breach of the contract. And since TRICARE is a federal government plan, this could potentially also be a violation of federal law. All it would take would be a phone call from this family to TRICARE complaining about your provider to potentially cause a lot of trouble for this practice. If the provider doesn't like the terms of TRICARE's payment conditions, they shouldn't be in the network.

It's understandable you don't want to make waves at a new employer, but you should address this issue with your supervisor or manager in a professional but firm manner and express that it's your understanding that this may not be compliant.

 

[SharonCollachi]

If Tricare is secondary, are you CERTAIN they require an authorization??? We stopped taking Tricare as primary due to some issues (they overpaid us for years and then told us "you should have known that was too much and informed us" ; our provider got so angry that we stopped seeing patients with Tricare primary), but with Tricare secondary we've never had to get an authorization for anything.

 

[Rbanskikum]

If Tricare is secondary, are you CERTAIN they require an authorization??? We stopped taking Tricare as primary due to some issues (they overpaid us for years and then told us "you should have known that was too much and informed us" ; our provider got so angry that we stopped seeing patients with Tricare primary), but with Tricare secondary we've never had to get an authorization for anything.

ABA is the only service that needs a pre-auth.

Our company is having the same issue with TRICARE. They said overpaid us and now trying to collect it back. They actually underpaid us. The owner is going to work on getting out of network.

 

[beckiw]

If you are still in network and allowed the patient to be seen, you still have a contract with Tricare and must follow the contract. Your option was to not accept the patient in the first place. Not WANTING to take it doesn't make you out of network. You're stuck on this one. You will end up writing off the PR from the primary insurance due to lack of pre-authorization.

I suggest you complete the paperwork to terminate your participation.