The Mysteries of TRICARE

If you have spent any time at all in the military; sponsor or dependent, you have had to deal with an entirely new vocabulary that most civilians never encounter or have to pay any attention to whatsoever.

"Dear, tomorrow I have to be in the AO at 0600 for PT and then go immediately to USR and QTB.  No ETA and it all might be OBE. "

Translation: I have to be at work at 6am and sit through mind numbing meetings with no definite end time and it might all fall apart.  Don't expect me for dinner.

My Dad was in the Army until I was in high school.  I was ROTC and then on Active Duty for nine years during which time I met and married my husband and had two children.  (It is an illness, this military service, but that's another post.)  The point being that I have been around this jibber jabber since birth.  I get military time, acronyms and service to country that makes family life nigh impossible to have.

My husband and I have lived in South Korea and El Paso and here (VA) since our children were born.  In Korea and El Paso we had no need of referrals to civilian medical care on a regular basis and so I have not learned the lingo of TRICARE.  Sigh.

Now I have under my TRICARE belt the following;  two major surgeries (both in military hospitals), physical therapy, speech therapy, five minor surgeries (four military, one civilian out of pocket), one home birth, one emergency surgery  (We got the bill since I bypassed even the insurance people in the ER...talk about sticker shock.), ambulance rides (two) and occupational therapy.  Not all for the same person.

So I spent 40 minutes on the phone with billing for TRICARE the other day with a very nice woman who explained all these terms to me.  I will try to relate them to you as I understand them.

****DISCLAIMER*****  Anything I say is not necessarily TRICARE policy and should not be taken as fact.

1.  P.O.S. (Point of Service) - This  service that you receive without a prior referral from your PCM (primary care manager) if you are TRICARE Prime or service you receive from any provider if you are on TRICARE Standard.  These are billed against your catastrophic cap for each year.

2.  Referral - A statement from your PCM that you require service from another provider (usually a specialist of some kind) which goes to TRICARE.  If you are on Prime you will be usually be able to make an appointment with the appropriate clinic / provider at a military treatment facility (MTF).  If there is no availability at a MTF you can be "referred out" to a network provider.  Several things to know here.
     A) No availability = no appointments available within 30 days.  If you are offered an appointment 27 days out and you think that's too long to wait you CAN ask to be "referred out"
     B)  Referrals to a MTF take about 24-48 hours to post in the system.
     C) Referrals that are referred out go through an additional approval process which can take up to five days.  You will be told to wait for a letter in the mail with an authorization code and name of practitioner where you can be seen.  This is ridiculous.  I have called every day during those five days and AS SOON AS there is an authorization number in the system the nice, helpful TRICARE people who can see from their computer screen that you are the crazy one calling them daily will gladly give you two or three places you can call for an appointment.  You get on line and look up Drs. Smith, Jones and Schmedlap and decide who you want to see (or not see).  Make an appointment with them and call the nice, helpful TRICARE people back and they will fax the authorization letter to the office of your choice.  (NOTE: Get the fax number when you make the appointment.  Tricare doesn't always have the correct, or any number sometimes, on file.)  They then send you the letter as well.  Keep for your files and take to the appointment with you.
     D)  Pre-authorization - when a provider sees you and determines that further services are needed they then are supposed to send a request to TRICARE for said services to be covered BEFORE services start.  If they do not request approval prior to beginning treatment they are docked 10% of the allowable TRICARE charge.  For example: Your son needs speech therapy.  He is authorized an evaluation appointment because he has a referral from a TRICARE provider.  He goes to said evaluation appointment.  They decide he does indeed need speech and occupational therapy.  He receives therapy for one year.  You start receiving billing statements from TRICARE stating that they are billing as POS (see number 1) because there is no referral on file.  You spend lots of time of the phone figuring out that said organization did not request pre-authorization for services prior to said services being provided.  There is no penalty to you (the patient and/or patient's family) but the organization providing services is getting docked 10% for EACH VISIT for the past YEAR.  Now, since this is only an example, one could tisk-tisk and move on.  But if it were REAL then one could become highly incensed that an organization providing valuable services is wasting money because they can't get their billing issues straight.  In which case you would begin making phone calls to them as well.  Their nice, helpful people would be glad to air their dirty billing laundry with you in order to appease you.  Maybe.
  

I must get to bed.  I will try to finish soon.  If I have missed something here or if you see something that is incorrect please let me know.

Next up: TRICARE Standard, OB care, homebirth and care while on the road.