Authorizing TRICARE Prime beneficiaries a one-time appointment for off-post treatment is helping medical access at General Leonard Wood Army Community Hospital, but beneficiaries not following established rules could be jeopardizing the effort.
The rules state that off-post authorizations are for one-time appointments with area providers, and all follow-up care must be done at GLWACH, said Diane Hell, TRICARE service representative supervisor.
Problems arise as active-duty family members are racking up bills for unauthorized follow-up care with off-post providers; retirees are doing the same and not paying associated co-pays. All total, GLWACH beneficiaries owe more than $3,000 in unpaid fees to civilian providers, according to Hell.
“If left unchecked, this could cause our off-post providers to withdraw from the TRICARE network, and that would be a tragic event for our health care system,” said Col. Theresa Sullivan, GLWACH commander. “We’re doing everything we can to meet Fort Leonard Wood’s health care needs, and we need everyone’s help and cooperation to be successful.”
Here’s how the system is supposed to work.
If no appointments are available when beneficiaries call the GLWACH appointment line, TRICARE clerks input an authorization for one appointment with an off-post provider, Hell said. If beneficiaries make additional appointments without authorization, TRICARE will not pay the claims, and the individual will have to pay for that care.
John Abshier, GLWACH’s managed care division chief, said beneficiaries who get unauthorized off-post health care are responsible for 100 percent of the claim and may also be billed a $300 point-of-service penalty. He said most people don’t realize that the treating beneficiaries seeking unauthorized care can also be penalized.
In addition to beneficiaries setting unauthorized appointments, retired service members and their families are not paying the required $12 co-payment for off-post care. These bills, if left unpaid, can be turned over to collection agencies to recover, Abshier said.
“If this continues, our civilian providers will be less willing to see our TRICARE beneficiaries and that would severely decrease access to care,” Abshier said. “We have some great civilian providers in our community and I’d hate to see our relationship tarnished because people didn’t fully understand the health care rules and the consequences for not complying.”
Abshier reminded everyone that TRICARE Management Agency rules require all beneficiaries enrolled to TRICARE Prime, other than active-duty family members, to pay a co-pay when not treated in a military treatment facility. This is discussed when signing up for TRICARE Prime.
“If our off-post providers would elect to stop treating our beneficiaries, the ripple effects on our health care system here would be many,” Sullivan said. “All we’re asking is for people to know what the rules are for getting off-post care and to comply with those rules. It would be much better for everyone.”
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