The TRICARE Question

TRICARE and other payers that tie their rates to Medicare have yet to adjust reimbursement per the CURES Act. What’s being done to change that?

Last month, CMS finally began moving forward with a plan (albeit a controversial one) to recoup providers per the CURES Act. However, that plan will only help some HME businesses, and many providers will continue to suffer from the full impact of competitive bidding’s national expansion — on claims that have nothing to do with Medicare’s DMEPOS benefit.

Case in point: TRICARE. TRICARE is the insurance program serving active duty and retired military personnel and the families, and, per law, the program’s reimbursement rates are tied directly to Medicare’s DMEPOS rates. When CMS's full implementation of national expansion of competitive bidding rates hit on July 1, 2016, TRICARE became the poster child for the “ripple effect” caused by that expansion.

Suddenly, a non-Medicare payer that providers had depended on for its Medicare-like reimbursement predictability and reliability morphed into its photo negative. Reason being: TRICARE’s rates were not only tied to Medicare reimbursement, but were discounted off those rates. If the national expansion’s full cuts fell somewhere between 35 to 60 percent off previous rates, then TRICARE was discounting roughly 30 percent on top of that.

Suffice it to say, if the national expansion rates were unsustainable, the TRICARE cuts were unsurvivable. Something had to be done.

“Right when the CURES Act was passed in December, I sent [American Association for Homecare President and CEO Tom Ryan] an email,” said Laura Williard, senior director of payer relations for AAHomecare. “I said, ‘I know this is great for Medicare, but there's a lot of problems here from the TRICARE and the managed care, Medicare Advantage world, and I want to make sure we do not forget about that for providers, as well.’ So, I started working on this from Day One.”

AAHomecare Senior Director Of Payer Relations Laura Williard is working with state associations and HME providers in hopes that she can “raise the noise level and the awareness of the situation” when it comes to TRICARE providers and other managed care and Medicare Advantage providers getting CURES Act recoupments.

Williard began by hiring health law attorney Asela Cuervo to get a legal opinion, so that AAHomecare could build a strong legal argument for why TRICARE must conform with the CURES Act rates, and recoup providers accordingly. That resulted in a letter that was sent to Dr. Robin Guicci acting secretary of the Defense Health Agency, which oversees TRICARE, and the three TRICARE contractors: Health Net, which oversees Tricare North Region; Humana Military, which runs Tricare South; and United Healthcare Military, which is in charge of Tricare West.

“It basically gives the argument that because they are bound to the Medicare fee schedule — based on legislative language — that they are going to have to go back and reprocess these claims,” Williard explained. “They get all of the legal citations, and the Tricare reimbursement manual citations inside of that.”

That effort happened earlier this year, and the initial response from TRICARE was that it was waiting for CMS to release its fee schedule for the CURES Act. Since CMS released that schedule in May, Williard has been in full-blown Whirling Dervish mode.

“Now that the fee schedule has been published, I have sent another letter to the Defense Health Agency, and I sent it to the three contractors, as well,” she said. “Again, stating that now that the fee schedule has been published, that it is bound by that to reprocess the claims. That’s just happened within the last couple of weeks that we sent that information to them.

“I'm making, pretty much daily calls — sometimes hourly calls — trying to get a status on this,” she added.

Providers Urged to Help

But Williard says her work for the association needs support from the industry. She is already coordinating with the state associations to help put pressure on the Defense Health Agency and the three TRICARE contractors by send copies of the letter that she has sent, and she also needs help from TRICARE HME providers.

“I also have a letter that providers can put on their letterhead, and their information, and it's a template that they can use and submit it on behalf of their company,” she said. “We're asking everyone to send this letter in to the Defense Health Agency, as well to raise the noise level and the awareness of the situation with them.”

Williard stressed that the letter is key when it comes to the Defense Health Agency, because the agency does not have an email address or phone number for providers to call. The only option is to send the letter via snail mail.

To download the Microsoft Word version of the letter that providers can send to the agency, as well as to the TRICARE contractors, click here.

Moreover, Williard stressed that TRICARE is only part of the issue, given that other payers tie their reimbursement directly to Medicare rates. The two other sizable programs are most of the Blue Cross-Blue Shield managed care plans and Medicare Advantage. Moreover, because most of the Blue Cross-Blue Shield programs only update their fee schedule on Jan. 1 of each year, the issue of CURES non-compliance is still making itself felt.

“We had some [apply bid expansions rates] in July [of 2016], but the majority happened in January of this year,” she said. “We're working through a lot of those plans, and having meetings with payers, and I'm working with state associations on that.”

To download a Microsoft Word document that contains various statistics and talking points that can help TRICARE providers in their discussions with managed care and Medicare Advantage, click here. The document covers items such as the Dobson DaVanzo price study, pricing comparison by region, and the declining numbers of providers. Additionally, the document provides many links to additional information and resources AAHomecare has made available to providers.

At present, the issue of the non-Medicare providers not adjusting their rates is “kind of the topic of the year,” according to Williard, and the providers supporting those plans must help keep the pressure on those payers.

“We're hitting it from every angle we can,” she said. “I know that the entire industry is really gung-ho on the Managed Care and Medicare Advantage side because they followed suit.… I feel positive about where we're at with the new Administration, and I think we are set up to have some success this year. That's what keeps me pushing.”

About the Author

David Kopf is the Editor of HME Business.

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