In 2022, the Tricare health care program for military members underwent significant modifications, resulting in widespread disruptions for service members, their families, and network providers across the country. Thousands of health care providers, particularly on the East Coast, have faced delays in payment, leading many to consider dropping Tricare patients or reducing their services. Beneficiaries on the West Coast have encountered challenges such as long wait times at call centers and delays in referrals and authorizations.
The upheaval in the system, which serves around 9.6 million people, has left military personnel struggling to access essential medical, behavioral, and mental health services. Concerns have been raised about the long-term impact of these disruptions. For example, in Tennessee, Sgt. Bo Heggins depended on Tricare to cover occupational therapy for his son with autism, but after providers went unpaid, his son’s progress regressed, causing distress for the family.
The Defense Health Agency, responsible for overseeing Tricare, has acknowledged the issues that emerged following the transition to a new contractor on the West Coast and in select Eastern states. While the agency initially stated that the new contracts would enhance health care delivery, challenges such as delayed payments to thousands of providers have persisted since the beginning of the year.
Efforts are underway to address these difficulties, with DHA spokesperson Brenda Campbell stating that the agency is working closely with contractors to resolve the situation. Providers, such as mental health clinics and individual practitioners, have reported substantial financial losses due to unpaid claims, impacting their ability to sustain their practices and provide vital services to military members and their families.
The ongoing disruptions highlight the urgent need for swift resolution to ensure that service members can access the care they require without further delays or complications.
A spokesperson for the company stated that the figure was under 1% of the total provider count within and outside the network. The company has been diligently working to address the backlog of unpaid claims, stating that they have identified and resolved the root cause of the issue that was caused by incorrect data. Expressing a serious commitment to TRICARE East Region beneficiaries and providers, the spokesperson apologized for the inconvenience caused.
On the other hand, TriWest Healthcare Alliance, the new contractor for the west region, did not disclose the number of unpaid providers. Acknowledging the challenges of major healthcare transitions, a TriWest spokesperson assured continuous efforts to find solutions to ensure military families receive the care they deserve. TriWest reported processing 1.6 million claims and issuing over 351,000 Tricare referrals and authorizations for care since January.
The Defense Health Agency (DHA) officials mentioned that it would take one to two weeks to confirm if the technical fixes have resolved the east region issues. They reported that the contractors have met the requirements to pay 98% of processed claims within 30 days and all claims within 90 days. DHA officials noted that no east region provider had left due to claims issues, but a few had exited in the west.
Regarding payment delays on the West Coast, DHA officials explained that claim payments are typically slower in the first month of the year to ensure accurate Tricare rates. They assured that claims are now processing faster and that TriWest is actively reaching out to providers who left the network to rejoin.
Numerous providers nationwide informed NBC News that they are still awaiting reimbursement. Some providers shared their struggles due to the delayed payments, leading to difficult decisions, such as pausing services for Tricare patients and laying off employees. The situation has put clinics in a financial crisis, with some considering charging patients out of pocket to stay afloat. The impact on mental health services for service members has become a growing concern for providers like MAPS Integrated Wellness in Fernandina Beach, Florida.
The text could be rewritten as follows:
“You’re talking about individuals who are in a suicidal state,” she remarked. “If their treatment is interrupted, they may opt to end their own lives. Transitioning to a new therapist is extremely challenging. Reopening and sharing one’s struggles all over again is no easy task.”
Ross Wise, a registered nurse collaborating with a psychiatrist at MAPS, mentioned that some of their patients include children facing difficulties at school and adults grappling with post-traumatic stress disorder. “It could potentially push someone further into a severe state of depression,” Wise added.
In Clarksville, Tennessee, Jenne Nesbitt-Decker, the owner and chief financial officer of Mariposa Behavioral Health Services, a small clinic specializing in treating children and teenagers with autism, shared that she had to reduce the number of available appointments by half due to unpaid fees and the departure of a provider.
If payments are not received by April 1, Nesbitt-Decker, a mother of four with a mortgage, expressed that she may have to discontinue services for Tricare patients, a service she has provided since 2007.
Eileen Huck, the National Military Family Association’s acting director of government relations, noted a growing concern that further departures of Tricare providers could exacerbate the existing shortage of healthcare workers. “This worsens an already challenging issue. What impact will this have on healthcare accessibility for service members and their families? This is truly troubling.”
The ongoing disruption has left Heggins, a service member with a young son diagnosed with autism, facing a difficult decision. His son’s provider informed NBC News that if the reimbursement matter with Tricare is not resolved within two weeks, the clinic will issue a 45-day notice to terminate services for current Tricare clients. New Tricare patients are no longer being accepted.
While Heggins, a military member for 16 years with plans for another four, had intended to stay in the Army, he is now contemplating leaving the military when his contract expires in June in search of better care for his son. “If my insurance won’t cover a service I deem essential, I may need to explore other insurance options,” he mentioned.
Heggins is considering selling his vehicle, relying on his wife’s car for transportation for their family of six to afford treatment out-of-pocket, or possibly taking out a loan. Each option presents its own challenges. “It would be a significant hardship,” he admitted. “I hope and pray that the Defense Health Agency resolves this promptly.”
