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Tricare In/Out of Network
Old 03-12-2015, 10:57 AM   #1
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Tricare In/Out of Network

I am hoping there is someone here that has Tricare Prime and might give some antidotal information.

Long story short, DW needs to see a specialist for probable surgery. The original specialist told her that her issue is outside his scope of experience and told her she needs to see another Doc that specializes in her condition (at Emory University). The "new" Doc and Emory Hospital are NOT listed as Tricare in-network providers on the Tricare provider list/website. Calling the new Doc, they say that they in fact DO take Tricare...we even went to far as to talk to the billing/finance folks and they too said they accept ALL Tricare including Prime. We call Tricare and they say that NO; they are out of network so it would be billed as POS (Point of service; 50% cost share) instead. Now, we find out today that DW now has an APPROVED referral from the supposed NON COVERED out of network Doctor at Emory! So what in the hell are we supposed to think? It's very possible that her procedure(s) could run in the several HUNDREDS of THOUSANDS of $$$.

So...if we have the referral, do we figure that they are considering them to be in-network? If she saw the Dr. under the POS option, there is NO referral required.

Thanks for the help!
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Old 03-12-2015, 11:04 AM   #2
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Originally Posted by FlyBoy5 View Post
I am hoping there is someone here that has Tricare Prime and might give some antidotal information.

Long story short, DW needs to see a specialist for probable surgery. The original specialist told her that her issue is outside his scope of experience and told her she needs to see another Doc that specializes in her condition (at Emory University). The "new" Doc and Emory Hospital are NOT listed as Tricare in-network providers on the Tricare provider list/website. Calling the new Doc, they say that they in fact DO take Tricare...we even went to far as to talk to the billing/finance folks and they too said they accept ALL Tricare including Prime. We call Tricare and they say that NO; they are out of network so it would be billed as POS (Point of service; 50% cost share) instead. Now, we find out today that DW now has an APPROVED referral from the supposed NON COVERED out of network Doctor at Emory! So what in the hell are we supposed to think? It's very possible that her procedure(s) could run in the several HUNDREDS of THOUSANDS of $$$.

So...if we have the referral, do we figure that they are considering them to be in-network? If she saw the Dr. under the POS option, there is NO referral required.

Thanks for the help!

I'm a little confused. Did you get the referral from your Tricare Primary Care Provider?


Mike
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Old 03-12-2015, 11:10 AM   #3
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I'm a little confused. Did you get the referral from your Tricare Primary Care Provider?


Mike

Yes.

Here's what happened. Primary doc (PCM) gave referral for 1st specialist. He said "outside my scope, you should see specialist XXX (Emory guy)." So we look on the Tricare provider list to see if he is on the in-network list and he is not (nor is ANY Emory affiliated Dr or practice). Meanwhile, PCM has gotten a referral from Tricare to see specialist #2 (that supposedly NOT in-network). We call Emory *and* the 2nd specialist and they all say, "yes, we take Tricare". We call Tricare to verify and they say, "NO...they are NOT in network". Ughhh....so confusing!
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Old 03-12-2015, 11:13 AM   #4
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Now would be a good time to mention that I hate insurance companies. Big surprise Im sure.
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Old 03-12-2015, 12:51 PM   #5
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Tricare and Tricare Prime are different. Just trying to find pediatrician's who took Tricare Prime for newborns being discharged from the hospital was a nightmare. Many docs (particularly university docs who don't deal directly with insurance) don't know that they are different. I found quite a few who took Tricare but not Tricare Prime.

That may be why you are hearing different things. Check with the office manager and be careful about what you sign.


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Old 03-12-2015, 02:39 PM   #6
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So...if we have the referral, do we figure that they are considering them to be in-network? If she saw the Dr. under the POS option, there is NO referral required.
The hospital and specialist are non-network but an approved referral gives you the lower patient responsibility afforded to in-network providers.

http://hmd.humana-military.com/South...2.asp?t=60#602

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What is the procedure for Prime enrollees who need specialty care? TRICARE Prime offers you a higher level of coverage, at a lower out-of-pocket cost, when your medical care is provided or coordinated by your primary care manager (PCM) and approved by the health care finder (HCF). One way that the PCM coordinates your care is through the use of referrals. Whenever you need to see a specialist or go to a hospital for non-emergency medical care, your care must be coordinated by your PCM and approved by the health care finder (HCF) at your local TSC. If you receive non-emergency medical or hospital care without a referral from your PCM, you will be covered under the Point of Service (POS) option. Beneficiaries are notified of routine specialty care referrals within ten days of the request.
What is the Point of Service (POS) option? Prime members utilize the Point of Service Option when they obtain non-emergency care without a referral from their Primary Care Manager. Under POS, beneficiaries are subject to a substantial deductible ($300 for an individual or $600 for a family) then a cost share of 50% of the TRICARE Maximum Allowable Charge (TMAC). Prime members may also be subject to additional charges (up to 15% over TMAC) if they see a non-network provider under the Point of Service option. To avoid the high POS charges, always consult your PCM before seeing another doctor.
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Old 03-12-2015, 02:51 PM   #7
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I always thought POS reverted to Standard which paid 75%.

If you're talking hundreds of thousands, I'd get it in writing in case you end up in court. Sad, but that's American medical car for you.
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Old 03-12-2015, 03:03 PM   #8
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I always thought POS reverted to Standard which paid 75%.

If you're talking hundreds of thousands, I'd get it in writing in case you end up in court. Sad, but that's American medical car for you.
Well, sort of. Under the POS option, you pay 50% of the allowable charges (plus 15% over if the provider tacks it on) after paying the yearly deductible. What can *really* hem you up is that the catastrophic cap DOES NOT APPLY.

Anyway, thanks for the replies. Doing further research/phone calls, it appears that we are good to go. The care that she requires is outside the scope of any of the "in network" providers, so the medical necessity allowed for a referral to be granted. It was a HUGE pain, but as I understand it...the Doc is the one that my DW *needs* to see and Tricare agreed.
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Old 03-12-2015, 03:11 PM   #9
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I've seen insurance have their mind changed when it was a specialist. My former manager has a 15 hour procedure done, one of the six figure specialists was not in plan. He won the argument based on this specialist was the ony one in network qualified for several hundred miles. But this was private insurance, never had to deal with Tricare. Good luck.
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Old 03-12-2015, 04:38 PM   #10
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FB5, I know nothing about Tricare but I want to wish your wife (and you) well through and following her surgery.
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Old 03-13-2015, 03:56 AM   #11
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Well, sort of. Under the POS option, you pay 50% of the allowable charges (plus 15% over if the provider tacks it on) after paying the yearly deductible. What can *really* hem you up is that the catastrophic cap DOES NOT APPLY.

Anyway, thanks for the replies. Doing further research/phone calls, it appears that we are good to go. The care that she requires is outside the scope of any of the "in network" providers, so the medical necessity allowed for a referral to be granted. It was a HUGE pain, but as I understand it...the Doc is the one that my DW *needs* to see and Tricare agreed.

Glad everything worked out. My wife has had to see a few specialists over the years and Tricare has always taken care of everything. Hope everything works out well for you and your wife.

Mike
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Old 03-13-2015, 10:58 AM   #12
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Glad everything worked out. My wife has had to see a few specialists over the years and Tricare has always taken care of everything. Hope everything works out well for you and your wife.

Mike
Thanks so much, I appreciate it! I know a lot of people complain about Tricare, but it's been a God send many times over for us. Sure, there can be some confusion and it can be frustrating at times but for a government run program, it works pretty well.
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Old 03-20-2015, 10:28 AM   #13
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Thanks so much, I appreciate it! I know a lot of people complain about Tricare, but it's been a God send many times over for us. Sure, there can be some confusion and it can be frustrating at times but for a government run program, it works pretty well.
I'll be finding out in about 2 1/2 yrs.

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Old 03-20-2015, 11:01 AM   #14
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I'll be finding out in about 2 1/2 yrs.

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FYI Marty. Right now just about everything that is related to Tricare prime is going through the military hospital scene. In Jacksonville Florida alone between 10 and 12 thousands Tricare Prime customers that were seeing doctors out in town were involuntary recalled back to the military medical facilities due to budget restraints. They were told we will see you and your family, or you have the option to switch to Tricare Standard and PAY MORE to see the doctor of your choice. Just something to keep in mind as you get closer to "your day"

Mike
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Old 03-21-2015, 02:55 PM   #15
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FYI Marty. Right now just about everything that is related to Tricare prime is going through the military hospital scene. In Jacksonville Florida alone between 10 and 12 thousands Tricare Prime customers that were seeing doctors out in town were involuntary recalled back to the military medical facilities due to budget restraints. They were told we will see you and your family, or you have the option to switch to Tricare Standard and PAY MORE to see the doctor of your choice. Just something to keep in mind as you get closer to "your day"

Mike
Or, stay away from the base! Warner Robbins is the closest MTF to us and it's about a 1.5 hour drive. Probably won't have to worry about getting 'recalled' to a mil hospital, which is 100% OK with me!

Although, there is the threat of losing Prime and getting 'stuck' with Extra which is still much more attractive than the idea of Tricare 'Choice' that's now floating around the halls of congress.
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Old 03-21-2015, 04:14 PM   #16
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Tricare Prime is the most predominant factor in my even being able to consider retiring early. But it comes at a price, that of complexity and confusion. I also have insurance from my employer, in which case Tricare Prime wants to be the secondary insurance. No matter that it's military PCMs doing the referral; for each referral, I need to get the in-network lists for both Tricare and my other insurance and make sure they're sending me to someone who's on both lists.

Makes me pine away for the days of "sick call", where you got care from "doctor du jour", but you didn't have to worry about who's paying what...
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