If you talk to someone moving through the Tricare coverage appeals process, you’ll probably find that they are frustrated.
At least that was the attitude of the folks I talked to over the last week. Because appealing a non-payment decision is frustrating. It’s long – maybe really long. And, after all is said and done, it may not end up in their favor.
While Tricare has a FAQ on their website detailing the appeals process, a new report sent by them to the Hill June 4 in response to a Congressional mandate sheds even more light on how things work.
Here’s a brief recap: there’s three levels of Tricare coverage appeals after a claim is denied — reconsideration, second reconsideration (for claims ruled “medically necessary”) or formal review (for those ruled “non-medically necessary”) and a hearing in which witnesses can be called. After all is said and done in the hearing, the hearing officer gives his recommendation to the director of Tricare.
The director or his designee either gives that decision the go-ahead or overturns the hearing decision completely or partially. Tricare may end up paying all, some or none of the claim regardless of what the hearing officer decides. A final decision took an average of about 346 days for non-medically necessary appeals between 2009 and 2013, according to the report.
Despite the director’s ability to overturn those decisions, the cover letter to the report, Jessica Wright, the Defense Department’s acting under secretary of defense for personnel and readiness, told Congress that “in developing this report, there was no evidence that the direct … summarily overturned hearing officers’ decisions.”
Tricare officials said “‘summarily” is not an accurate description of the director’s review process. Instead, they said, decisions are “reviewed” and the director states the “reason for disagreement with the recommended decision and the underlying facts supporting such disagreement.”
Of the 9,246 appeals that were started in 2013, 72 made it to the hearing level. Of those, 16 were given “favorable” rulings, 14 “unfavorable,” 11 “partially favorable” (meaning Tricare paid a part of the claim) and 31 “other dispositions” meaning that the case did not actually go to a hearing, perhaps because the appealing user decided to abandon it.
Of the 124 hearings held between 2009 and 2013, 106 of the hearing officer’s decisions were adopted by the director and 18 were not. In 10 out of those 18 cases, no payment was made even though the hearing officer recommended it. In the remaining eight some payment was made — in four cases more than the hearing officer had recommended.
Have you been through the Tricare coverage appeal process? What was your experience? Share in the comments below.