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If you or your family have other health insurance with an HMO and plan to use TRICARE, please read this important information to avoid paying higher costs for care. If you have other health insurance, federal law requires that TRICARE only pay after the other insurance is used. Only Medicaid and TRICARE supplemental plans are exempted from this rule. If you have health insurance with an HMO and wish to use TRICARE, be sure that the providers you use are available through both your HMO and TRICARE. By doing so, you will avoid paying costly health care bills. You must know what the coverage requirements and limitations are for both your HMO and TRICARE. If your other insurance is an HMO (Health Maintenance Organization) and you choose to see a provider outside your HMO plan, under federal law, TRICARE cannot cover your charges and the provider can bill you for the entire amount. HMOs limit their coverage to a panel of providers and will only pay if you see one of the providers in the HMO's panel. For instance, you want to see a family counselor. However, you don't want to see the therapist available within your HMO's plan - you'd rather see a psychiatrist available through TRICARE. TRICARE cannot cover the claim in this case because you chose to go outside your HMO plan. TRICARE will pay secondary to a HMO in certain instances, such as when the service is not a benefit of the HMO, but is a benefit of TRICARE. Examples of such situations include mental health care or prescription coverage. You must submit to TRICARE an 'explanation of benefits' statement from your HMO showing the denial of the service requesting to be covered by TRICARE. In some cases, neither your HMO nor TRICARE will cover a service, such as seeing a chiropractor. If you want a service that isn't covered by your HMO or TRICARE, be prepared to pay for it out-of-pocket. (Source: Foundation Health Federal Services, Inc.)
The information listed below was received from Palmetto Government Benefits Administrators (PGBA) Technical Support and is provided for your information (PGBA processes claims for the TRICARE regions indicated). Toll-free telephone numbers for PGBA Customer Service Offices:
A complete list of toll free numbers and mailing addresses can also be found in the "Contact Us" section of PGBA's web site at http://www.myTRICARE.com. (Source: PGBA Technical Support
TriWest Healthcare Alliance, a managed-care support contractor for the Department of Defense (DoD), and Express Scripts, Inc. (NASD: ESRX), one of the nation's largest independent pharmacy benefit managers, jointly announced on August 8 the first successful implementation of the military's new Pharmacy Data Transaction Service (PDTS). Approved under the FY 2000 Defense Authorization Act and developed under the auspices of the Office of the Secretary of Defense for Health Affairs, the PDTS is the first phase of an integrated pharmacy program intended to enhance patient safety and improve the quality of pharmaceutical care within the Military Health System (MHS). "This is a real milestone," said David McIntyre, TriWest president and chief executive officer. "Thanks to the excellent work of Express Scripts, TriWest is the first of the five regional MHS managed-care support contractors to go live with PDTS implementation. This initiative is critical to the effective management of the DoD pharmacy benefit, and the Express Scripts information systems team came in right on target."
TriWest and Express Scripts began working on PDTS implementation approximately one year ago. "Integrated prescription data is essential for patient safety," said Barrett Toan, Express Scripts president and chief executive officer. "But the bottom line is that accurate utilization profiling and screening hinge on top-notch information systems capability. That's why IS operations are such a strong focus for us. We're very pleased that we were able to help TriWest implement this program so smoothly." PDTS, a centralized data repository, creates the first capability to record information about prescriptions filled for the 8.3 million beneficiaries who receive pharmaceutical care within the Military Health System (MHS). Pharmaceutical utilization information will be submitted to PDTS from 587 Army, Air Force and Navy treatment facilities worldwide, as well as from the retail pharmacy networks of five regional managed care support contractors (including TriWest) and the National Mail Order Pharmacy (MNOP).
Previously, each pharmacy option maintained separate prescription profiles that could not be integrated. PDTS is intended to improve the quality of prescription services and enhance patient safety for members of the highly transient military population by enabling pharmacists to conduct online prospective drug utilization review (clinical screening). Each new or refill prescription will be viewed against a patient's complete pharmaceutical history before it is dispensed, helping to safeguard against potentially dangerous drug interactions, therapeutic overlaps and duplicate treatments.
Express Scripts is one of the nation's largest independent full-service pharmacy benefit managers (PBMs). Express Scripts provides fully-integrated PBM services, mail-order pharmacy services, benefit design consultation; disease management; medical and drug data analysis services; medical information management services, including provider profiling and outcome assessments, through its subsidiary, Practice Patterns Science, Inc.; and informed decision counseling services through the Express Health Line(SM) division. The company also provides non-PBM services, including infusion therapy, through its subsidiary, Express Scripts Infusion Services and distribution services through its subsidiary, Express Scripts Specialty Distribution Services, Inc. Express Scripts is headquartered in St. Louis, MO. More information about the company can be found at http://www.express-scripts.com
TriWest Healthcare Alliance is a Phoenix-based management service organization that is contracted with the Department of Defense for the managed care support and administration of the TRICARE program in the TRICARE Central Region. TriWest's goal is to provide the TRICARE beneficiaries in the 16-state region with access to cost-effective, quality health care and superior customer service. More information about TriWest and TRICARE can be found at www.triwest.com
(Source: TriWest Healthcare Alliance, (602) 564-2074; rwolfersteig@triwest.com; rsoderst@express-scripts.com)
By Gerry J. Gilmore
American Forces Press Service
WASHINGTON, Aug. 17, 2000 -- TRICARE beneficiaries are now just a phone call away from accessing help to resolve creditors' concerns over late or unpaid medical care bills.
While service members, retirees and family members consider the TRICARE health care system a valued benefit, they don't like threatening calls and letters from collection agencies harassing them over unpaid medical bills.
"These problems tend to occur when physicians are impatient for payment, as they have a right to be. (However,) the burden of dealing with this system, of any system, should not fall on the individual (service member)," said Bernard D. Rostker, undersecretary of defense for personnel and readiness, in a recent interview with the American Forces Information Service.
Service members and other TRICARE beneficiaries raised the bill-collector issue at the Military Family Forum May 31 at the Pentagon, Rostker said. He responded June 27 with a memorandum directing the services' health affairs organizations to establish the Debt Collection Assistance Officer program within 30 days.
Implemented July 26, this new program formally established DCAOs as local points of contact that service members and other eligible TRICARE beneficiaries, stateside and overseas, may use to resolve medical bill payment issues.
The new DCAO system, Rostker said, creates a formal method for beneficiaries "to gain help in dealing with what admittedly is, as is every health maintenance organization, a bureaucratic process."
He said there could be resolutions where beneficiaries owe money, "in which case we're prepared to work with him or her to find out how we can be most helpful in resolving that issue." He also noted "situations where the bill is misplaced ... we can work with the doctor or credit organization to resolve that."
The main thing, Rostker said, "is we don't want our people to feel they've been isolated. This is a part of the system and we want to be able to help them if and when this kind of situation occurs."
He said he has received varying feedback regarding the prevalence of conflicts involving TRICARE bill payment. "I've asked some people, and one of the services (said) they thought this happens a couple of hundred times a year, and other people think it occurs a couple of hundred times a month."
"We will know better how often this occurs by how people use this service," he said.
Before the DCAO program was implemented, DoD resolved dunning letters and bad credit reports involving TRICARE payments on an ad hoc basis, Rostker said. Besides this method not working very well, it left no central registry to track the resolution of late or unpaid TRICARE payments, he said.
"Now, it will come to our attention because we've taken on the responsibility of being the agent for our service members in trying to resolve these situations," he said.
TRICARE beneficiaries who've received dunning letters or bad credit reports can now just phone the designated debt collection assistance officer, who will coordinate a review/research process.
DCAO Program Manager Marcia Bonifas said the beneficiary provides the assistance officer with documentation --collection agency letters, bills and contractors' explanations of medical benefits. The DCAO in turn sends the information to the contractor's bill processing or collections unit, she said.
"The debt collection assistance officer will ask the collection agency to hold up further work until the research is done, and that will be done in less than 30 days," Bonifas said. "We cannot force them to hold up, but we can ask for their cooperation."
Bonifas said the DCAO receives the completed research information and then notifies the beneficiary in writing.
Contractors will research claims less than six years old, Bonifas said, but they won't have any documentation for claims older than that. These older claims will be researched by a special TRICARE Management Activity claims evaluation office in Aurora, Colorado, she said. Although DCAOs can help beneficiaries to research and resolve TRICARE payment problems and related credit reports, they cannot provide legal advice or repair bad credit ratings, she said.
TRICARE beneficiaries can click a hyperlink button on the DCAO information Web site, http://www.tricare.osd.mil/dcao/ to identify their local assistance officers, stateside and overseas, Bonifas said. In a month or two, active-duty service members will see the phone number for their local DCAO on their leave and earnings statements, she added.
In addition, beneficiary counseling and assistance coordinators at all military hospitals and clinics and at TRICARE lead agent offices can provide assistance for all other TRICARE issues, such as claims, explanation of benefits and enrollment procedures, Bonifas said. BCACs are listed on the Web at http://www.tricare.osd.mil/tricare/beneficiary/bcac_dir.htm
Rostker called the DCAO program a timely response to important service member concerns.
"We believe the program is in place, we have training manuals, people in place (who are) responsible by name, Rostker said. "We're looking forward to gaining feedback from our service members, their beneficiaries and families to make sure this program is the help we designed it to be."
For more information about TRICARE, visit the Military Health System/TRICARE Web site at http://www.tricare.osd.mil
By Staff Sgt. Kathleen T. Rhem, USA
American Forces Press Service
WASHINGTON, Aug. 25, 2000 -- It's your health. Defense medical officials want you to know simple steps you can take to safeguard it as a DoD healthcare patient.
"We want to make people understand there are certain things they can do that will really minimize patient errors and, even more, will help draw them into their own care," said Dr. John Mazzuchi, deputy for clinical and program policy in the Office of the Assistant Secretary of Defense for Health Affairs. "An individual person is responsible for his or her own health care, too. We want them to be in a partnership with their doctor."
To help build this partnership the Quality Interagency Committee, a group of healthcare professionals from several federal agencies that deals with quality and safety issues in medicine, came up with a list of five things individuals can do to safeguard themselves from medical errors.
** Speak up if you have questions or concerns. Mazzuchi said he wants patients to understand asking questions shouldn't be seen as challenging physicians. "I'm sure it can be somewhat uncomfortable for a young enlisted person or a spouse of a young enlisted person to be sitting in front of a full colonel who's the physician and start asking questions," he said.
Mazzuchi stressed he's not suggesting patients question the doctor's intelligence, integrity or motivation. "But if you have questions as a patient, you need to get those questions answered," he said, noting that patients do a better job of following instructions if they understand the instructions clearly.
** Keep a list off all medications you take. "Clearly, medication errors are a major concern because we write so many prescriptions," Mazzuchi said. Because medications can counteract each other or cause a serious reaction when combined, he said, it's critical for patients to tell their doctor and pharmacist what medications they're taking, including over-the-counter drugs and supplements, and any allergies they might have.
** Make sure you get the results of any test or procedure. "Don't assume that because the doctor has not gotten back to you in two weeks, everything was fine," Mazzuchi said. "That doesn't mean that it couldn't have been lost in the mail; it could have been misplaced someplace; the doctor thought the nurse was calling, the nurse thought the doctor had called."
Individuals should call their healthcare provider and ask for an explanation of results they don't understand. "Sometimes people write right instead of left, or they write yes instead of no, or positive instead of negative -- not because they're bad people but because we all make mistakes," he said. "If a result comes back that seems strange, I think it's important for any patient to pick up the phone and call the doc, call the nurse, call the lab tech, whomever you're supposed to call, and say, 'I don't understand these results; can you go over them with me?'"
** Talk with your doctor or healthcare team about your options if you need hospital care. "Certain hospitals do a better job with certain types of surgery than others," Mazzuchi said. "So "If something different happens from what the physician tells you to expect, then you need to bring that to the physician's and nurse's attention immediately. You may be having something bad happening to you, and you need to say so right away," Mazzuchi said. It's easier to treat you when a problem is brought up right away than when you wait, he noted.
Mazzuchi said DoD is also working to educate healthcare providers on these issues to make this partnership between provider and patient easier. "We are educating both those physicians who are coming up through medical school and those who are already in practice about the need to go over options and to bring the patient into the health decisions that are being made," he said.
Medical errors might always happen, but there are ways to mitigate their seriousness. "Patient errors don't happen because you have bad people, they happen because health care providers - - physicians, nurses, psychologists, whatever the healthcare professional is -- are human beings and they make errors," Mazzuchi said. "They get tired; they get overwhelmed; they get absent-minded; and they make mistakes.
"But when you're the most informed, when you really know what's going on about your healthcare, when you understand your options, when you understand what's probably going to happen to you and what's going to happen to you after you recover, when you understand what your lab results are and what they mean, you can take better care of yourself," he said.
