Tricare transition creates billing ‘nightmare’

Friday, May 25, 2018

HAMPTON, Va. – Ever since Tricare transitioned to a new contract administrator, providers say their claims aren’t getting paid at all, or very slowly.

“It’s been a nightmare and we haven’t been getting any real response from them,” said Matt Russell, vice president for ABC Health Care in Hampton, Va.

Humana Military took over the Tricare East contract from Health Net Services on Jan. 1, when Tricare consolidated from three to two regions, East and West, and outsourced the billing to Wisconsin Physician Services.

Wisconsin Physician Services seems to have been unprepared for the volume of claims, say providers.

“I feel their infrastructure was set up to be a secondary processor,” said Justin Miller, CEO at ABC Health Care. “This was supposed to be a seamless transition.”

As a result, ABC Health Care has seen its cash flow decrease by $450,000—55%—from the fourth quarter of 2017 to the first quarter of 2018.

Further delaying payments: Providers are getting requests for CMNs after they send in claims that have been authorized for payment, they say.

“We don’t put out anything without an authorization,” said Chris Smythe, vice president at Tycon Medical, which has locations in Norfolk and Portsmouth, Va. “There shouldn’t be delays. We have tons of claims that haven’t been paid.”

Other issues have included Humana Military saying it never received a claim and it paying claims at drastically different amounts for the same item.

While there has been a slight improvement recently, providers say they are frustrated. ABC Health Care had a call with senior-level representatives from Humana Military and WPS last week and has another scheduled for this week.

“We’re hearing some of the right things from them and it sounded like they are fairly aware of some of the claims-related issues,” said Miller. “But it sounds like they’ve been aware for five months and the backlog still isn’t sorted.”


Our claims department has been vigorous with calling in for claim status and no one could explain why a claim that was pre-authorized is taking 5 months to finalize.

Our capped rental claims are now being paid out in month 10. I think they are classifying them as inexpensive routinely purchased items vs true capped rentals.Our Breast Pump claims are just not paying and we are told they are "discussing" the allowable.  Not sure if this new allowable will be retroactive?Good to know we are not alone in the fight.I finally have upper level person email with me about our issues but as stated above they seem to know there is a problem but are not really doing anything to fix it.


Has your company seen changes yet?

No real changes have taken place. Payments are still coming in very slowly and we seems to be getting the same responses. Anyone notice any differences lately?

DME provider in Michigan here. Since the transition to Tricare East, a majority of our claims are being underpaid and processing is SLOW. We are forced to send our claim paper because they require CMN with the claim rather than just on file, which slows down the process already.... then when they finally process months later, we are being paid around 30% less than our contracted amount. Numerous calls have been placed requesting adjustments, all of which were canceled because they claim no additional payment is due. It has taken almost a month to get a response from our provider rep, and she as well as others I have spoken to have absolutely no sense of urgency about claims that are 10 months old and still not paid correctly. Absolutely ridiculous! 

Sorry to hear you are also dealing with this. Would you be willing to speak with HME News about the issues you've had?