TRICARE to Comply with CURES Act

Letters from military insurance program indicate it will work with providers to adjust past claims to align with CURES reimbursement rates.

TRICARE will reprocess claims from July 1 through December 31, 2016 to reflect adjustments to the fee schedule mandated by the CURES Act. The news came via letters sent to HME providers that had previously asked TRICARE about whether it would be adjusting reimbursement for claims according to the Act.

“You are correct TRICARE uses Medicare’s DMEPOS fee schedule, Medicare reduced their rates in the second half of 2016, and a subsequent resolution (the 21st Century Cures Act) delayed that reduction, and retained the original, higher rates for claims with dates of service between July 1 and December 31, 2016,” the letter read. “TRICARE followed suit and we suggest you resubmit any claims adjudicated under the reduced rates to the Managed Care Support Contractor (MCSC) in your region for reprocessing.”

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. TRICARE’s rates are not only tied to Medicare reimbursement, but are discounted off those rates. While the national expansion’s full cuts fell somewhere between 35 to 60 percent off previous rates, TRICARE was discounting roughly 30 percent on top of that.

Focused Advocacy Battle

Since that time several organizations, including the American Association for Homecare, ACMESA and various providers and advocates have been steadily working for several months to convince Defense Health Agency, which runs the TRICARE program, and the TRICARE contractors, to adhere to adjust reimbursement rates per the CURES Act, and recoup providers for the difference on undercut reimbursement during the time the rates were not adjusted.

“This is a big win for the industry and that hopefully other payers who base reimbursement off of Medicare will follow suit,” said Laura Williard, AAHomecare’s vice president for payer relations, in a conversation with ACMESA executive director Beth Bowen. “Insurance payers are watching what others are doing and this is a BIG message to them.”

“I am ecstatic to see that TRICARE is aware of the CURES-mandated adjustments and is ready to implement them,” said Tyler Riddle, vice president of HME provider MRS Homecare and president of the Georgia Association of Medical Equipment Suppliers. “Now the HME community needs to keep making the case to TRICARE and other third-party payers that the current bidding-derived rates are unsustainable going forward and need to be adjusted on a long-term basis.”

How to Get Recouped

Providers that have not already done so should submit the letter titled “Sample Provider Letter to DoD on CURES-Mandated TRICARE Reimbursements,” said Laura Williard, AAHomecare’s vice president for payer relations. A sample of such a letter in Microwoft Word format can be found on payer relations resources page.  Sending such a letter should an elicit a response letter from TRICARE.

Providers should resubmit a small, initial batch of claims to check that they are correctly reprocessed prior to sending all claims, according to Williard. This would save a provider from having to resubmit all its claims multiple times if its TRICARE contractor denies or improperly processes them.  

About the Author

David Kopf is the Editor of HME Business.

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