Medical providers in Tricare’s West Region continue to be reluctant to accept military patients because UnitedHealthcare, the new regional contract manager, is slow to reimburse claims, say patients and physicians in the 21-state area.
Tricare Prime beneficiaries have told Military Times they still face problems getting appointments despite an effort announced May 2 that allows them to get specialty care without prior authorization.
The patients say doctors are not being paid promptly because they are showing up in the UnitedHealthcare Military & Veterans system as lacking proper referrals.
According to the office of Rep. Doug Lamborn, R-Colo., at least one specialty care provider in Colorado Springs has not been paid since April 1 and is owed more than $100,000 by UnitedHealthcare.
In California, a Marine Corps family member who asked not to be identified because he doesn’t want to be singled out to UnitedHealthcare said he has deferred necessary diagnostic tests because he can’t get an appointment under the waiver.
“My doctors are not taking the waiver because they accepted it for a couple of patients but haven’t gotten paid ... there is no referral in the system,” he said.
Maria Kadlec, a Tricare Prime beneficiary in Murrieta, Calif., said she is now judicious in making appointments with her neurologist because she spent a month going without needed pain management care while battling UnitedHealthcare for referrals.
Now, she says, she has to argue for every appointment.
“I don’t want to waste my visits. And I don’t want to go through this again with these people,” she said.
Tricare’s problems with UnitedHealthcare Military & Veterans services began immediately after the company assumed management of the regional contract April 1.
The company experienced an overload of calls to its customer service line, and its Web-based assistance program was inadequate to handle demand. Referrals began piling up in UnitedHealthcare’s system and were being processed in weeks rather than days, as was done by previous contractor TriWest Healthcare Alliance.
To reduce the backlog and speed the process, the Pentagon announced May 2 it would allow Prime beneficiaries in Tricare West to seek recommended specialty care without obtaining authorization or paying penalty fees.
The waiver period was later extended through June 18.
Since the waiver announcement, however, physicians still are experiencing payment problems, according to an administrative assistant in a California physician’s office who asked not to be identified. She said customer care is affected.
“It was taking up to a week to get even urgent referrals. No wonder they were having problems,” she said.
Tricare referred questions about the ongoing issues to UnitedHealthcare. TMA officials have called the company’s efforts to meet contract requirements for referrals and authorizations a “failure” and said they are “closely monitoring UnitedHealthcare’s leadership’s efforts to improve the ... process as well as other customer services.”
“The Tricare Regional Office West is working closely with UnitedHealthcare to address issues, reduce backlogs and ensure beneficiaries get the quality health care and service they deserve,” according to talking points drafted for Tricare officials.
UnitedHealthcare said it has responded aggressively to the referral problem, largely clearing the backlog and “now routinely processing new referrals and authorizations in a timely manner.”
Payments to providers also are meeting government guidelines that require the contractor to reimburse within 30 days, said Bruce Jasurda, vice president for corporate communications.
“UnitedHealthcare is current with all providers who have submitted valid claims to us,” Jasurda said.
The company welcomes any provider to contact them regarding perceived delays, he said.
UnitedHealthcare “conducts routine and comprehensive outreach to the network provider community,” he said. “When issues, questions and concerns arise, we work with each individual provider to address their needs and resolve their concerns.”
Kadlec, who receives weekly shots to alleviate the pain of nerve damage caused by a fall, went four weeks without receiving care while waiting for the problem to be fixed.
She said she resents the delays in care and misses TriWest, the company that managed the West Region for 16 years before the Pentagon awarded a new contract, worth up to $21.5 billion over five years, to UnitedHealthcare.
“You should have been prepared. You knew you were taking over the contract a year ago and we’re suffering because you weren’t ready?” Kadlec said, addressing UnitedHealthcare.
The Marine Corps family member, a veteran, said he has spent more than 40 hours on the phone trying to resolve his problems and still can’t get an appointment for referred services.
“It’s upsetting that we can’t get the care we need, and I know we’re not alone,” he said.