This year, the military's healthcare programme has been changed, causing nationwide disruption to millions of service members, their families and network providers.
Around 16,000 healthcare providers have not been paid for months on the East Coast alone, and many are forced to consider dropping Tricare patients, reducing time, or closing clinics. On the West Coast, beneficiaries struggle with many issues, including long call centre waits and stalled referrals and approvals, federal officials said.
The disruption to the network that benefits approximately 9.6 million people has led military members to scramble to secure medical, behavior and mental health services for themselves and their loved ones.
Army Sgt., Tennessee. Bo Heggins has relied on Tricare for many years to cover occupational therapy for her 8-year-old son with autism. Up to 8 hours of time with a provider every week helped my son learn life and conversation skills. Progress was visible, and Heggins, 35, wanted his son to grow up and lead a happy and independent life.
Then in mid-February, when Heggins and his wife tried to schedule another routine appointment, they were one of many whose providers were not paid by Tricare, threatening future coverage. In all the chaos, his son had not had a session since then and began to regress. “There's no improvement anymore,” Heggins said, beginning to cry. “My son is my heart. And I want him to be the best person he can be.”
The Defense Health Agency, which oversees Tricare, acknowledges that several challenges have arisen nationwide since January 1 after new contractors began managing profits in the six eastern areas that have been reassigned to the West Coast and the West Region.
The DHA previously said that new contracts will “improve healthcare delivery, quality and access” for US beneficiaries.
This situation is unacceptable.
Tricare provider Brenda Stevens
In a statement to NBC News, DHA spokesman Brenda Campbell said the agency is working with contractors to resolve the issue. Some say they owe more than $100,000.
“This situation is no longer acceptable,” Brenda Stephens said. Brenda Stevens filed a $180,000 claim for the services offered to military personnel by a mental health clinic in San Diego this year.
Another San Diego mental health provider said that since January it only had around $1,000 to spend on monthly income received through cash-paying patients.
Clinical psychologist Roger Queston, 50, said his personal practices earned around $50,000 on unpaid Tricare claims. He said he had to be soaked up in his savings and hadn't bought one item this year that he didn't need.
“There are times when I like, what am I going to do?” he said.
A spokesperson for the Humana Army, a regional contractor in the eastern region, said the company had learned in early January that a “small percentage” of the billing management system provider's records had outdated or false data.
This issue affected fewer than 16,750 providers. A Humana spokesman said the figure is less than 1% of the total number of providers inside and outside the network.
The company said it is “working 24 hours a day” to clear the backlog of unpaid bills.
“We have identified the root cause of this issue and fixed a large portion of the issues caused by incorrect data,” the spokesman said. “We take our commitment to beneficiaries and healthcare providers in the Tricare East area very seriously and apologize for the inconvenience and frustration that this issue has caused.”
The new contractor in the western region, the Triwest Healthcare Alliance, did not say that no number of providers have been paid.
“All major healthcare transitions of this size and scale pose challenges. We are constantly working seven days a week to implement solutions, as there is nothing more important than ensuring the care that military families have acquired,” a Triwest spokesperson said in a statement.
Triwest said it has processed 1.6 million claims since January and issued over 351,000 Tricare referrals and care authorizations.
In a statement from NBC News, DHA officials said it would take a week or two to determine whether the technical fixes resolved the issue of the Eastern region.
The agent stated that the contractor met the contractual requirements to pay 98% of claims processed within 30 days and paid all claims within 90 days.
DHA officials cited the contractors and said that East area providers have not left the network due to billing issues, but some have left in the West.
Regarding the West Coast payment issue, DHA officials said that bill payments are “always slightly slower” in the first month of the calendar year each year to ensure that Tricare fees are applied properly. The contractors confirmed that the numbers and provider information for each claim were correct before the money was paid, they said.
“This time frame is now passed and the claims are now flowing much faster,” the official said. “In addition, Triwest is actively contacting the few providers who have left the network and asking them to rejoin their network.”
NBC News spoke to more than half a dozen providers across the country. Facing a sudden cash flow crisis, many have had to make difficult and heartbreaking decisions.
“You're forced into an impossible situation”
In San Diego, Stevens received a $75,000 loan in early February, but got her clinic through two payrolls. By the end of February, she had to suspend services due to layoffs of some of the clinic's 350 Tricare patients (“hopefully form”) and seven employees.
“It was nothing but devastating. I feel a response all over my body now,” she said in tears. “We've been forced into an impossible situation. We can't continue to treat them without paying, and they can't find other providers.”
A clinic in Florida, which provides psychiatry and therapy services to around 300 people, recently decided that since January 1st it must stop treating Tricare patients after earning an unpaid bill of more than $100,000.
You're talking about people committing suicide.
Beth Matricia, Office Manager
Matricia, who manages map integrated wellness for the military community in Fernandina Beach, said: Matricia said she and other staff fear that Fallout could have an even more impact on her and the other staff as it is likely that Fallout will not be able to pay up to $150 per session.
“You're talking about people who are committing suicide,” she said. “If you stop caring for them, they can choose to end their lives. It's very difficult to move the therapist. It's really hard to open again.”
Ross Weiss, a registered nurse who works with psychiatrists on the map, said some of the patients are children struggling at school and adults who deal with post-traumatic stress disorder.
“It could have taken someone down to deep depression,” Wise said.
In Clarksville, Tennessee, Jeanne Nesbitt Decker, owner and chief financial officer of Mariposa Behavioral Health Services, a small clinic treating children and teens with autism, said the number of available appointments should be cut in half to compensate for the lack of payments and the loss of Provider who lost QUIT.
If she has not yet been paid by April 1st, Nesbitt Decker, who has four children and a mortgage, said she must stop serving Tricare patients since 2007.
Irene Huck, director of government relations at the National Association of Military Families, is growing concern that providers will continue to leave Tricare, exacerbating the shortage of existing healthcare workers.
“It exacerbates an already difficult problem,” she said. “What does that mean for healthcare access for service members and their families? That's really annoying.”
The months of rapid change left Heggins, a service member whose young son has autism, to make his own painful choice.
His son's provider told NBC News that if Tricare does not resolve its refund issues in two weeks, her clinic will send 45-day notice to current Tricare clients to end the service. Her office has already stopped accepting new Tricare patients.
Heggins has been in the Army for 16 years and plans to give him another four years, but he said he is considering leaving the Army when the contract ends in June to find better care for his son.
“If my insurance doesn't cover what I think is an essential and necessary service, I might need to consider covering it with other insurance,” he said.
Other options include selling cars and relying on his wife's car to transport six families, forcing them to be treated as a self-pay or giving them a loan, according to Heggins. He sees hardships in any decision.
“That would be very difficult,” he said. “I hope the Defense Health Agency thinks this is coming out in a timely manner.”
