Appealing a Tricare decision to the highest level within the Defense Health Agency may take nearly a year but that doesn't necessarily mean those decisions go against beneficiaries in the end, according to a report recently provided to Congress.
In fact, of the 124 cases that made it to the highest level of appeal from 2009 to 2013, 106 — or 85 percent — of lower-level appeals rulings in favor of beneficiaries were upheld.
During that time, Tricare beneficiaries appealed 65,336 denials of claims, resulting in 3,913 formal reviews and 303 hearings at the Defense Health Agency level, according to the report.
As part of the 2014 Defense Authorization Act, the Senate required the Pentagon provide a report on the Tricare appeals process after beneficiaries and advocacy groups raised concerns about fairness in the process.
A few well-publicized cases, including one involving a disabled Texas teenager whose horse-based physical therapy was recommended by a Tricare hearing officer but later was denied by the Tricare appeals director, prompted the Senate requirement.
The appeals process can involve up to three levels. After beneficiaries receive an initial denial for reimbursement, they can appeal to their regional Tricare contractor; if the denial is upheld, the appeal goes to Defense Health Agency Appeals or Quality Monitoring Contractor, depending on the nature of the case; and finally, an appeal can be made to an independent hearing officer.
In 2013, just 27 hearings reached that final level. The hearing officer adopted the lower-level recommendations in 23 of those cases and overturned previous decisions in the other four.
"There's no evidence that the director of the Tricare Management Activity summarily overturned hearing officers decisions," Undersecretary of Defense for Personnel and Readiness Jessica Wright wrote in a letter accompanying the report.
Still, those facing the appeals process can wait a long time and Tricare is working to improve work flow and case management efficiency, Wright said. According to the report, beneficiaries waited nearly 70 days for a formal review and 298 days for a hearing in 2013. That's actually an improvement over 2012, when those wait times were 83 days and 342 days, respectively.
Air Force chaplain Capt. Mark Traeger is all too familiar with the lengthy appeals process and what he perceives to be arbitrary decisions by Tricare contractors and the Defense Health Agency.
His son Toby, 1, has Down syndrome and Hirschsprung's disease and needed surgery last September to allow him to defecate properly. The surgery was approved, but a second procedure that entailed using Botox to relax his muscles was denied because it was deemed "cosmetic."
Then, when his parents took Toby home from the hospital the same day as the previously approved surgery, Tricare denied that claim as well, because the approval was for an in-patient procedure only.
The Traegers now face a $17,000 bill for the operation and are at a loss to understand why their claims and appeals have been denied.
"As his parents, we're really familiar with Toby's medical requirements and we knew how to care for him post-surgery, so the doctors allowed us take him home. But it makes no sense. Tricare would rather we have kept our baby in the hospital overnight?" Traeger said.
Tricare officials could not comment specifically on Traeger case but said the appeals process exists for a reason.
"If the recoupment of payments is based on the care not meeting coverage criteria, a beneficiary should have been provided appeal rights and we would encourage them to do so," Tricare officials said in a written response to Military Times.
Traeger said he remains in talks with Tricare and Health Net Federal Services, contractor for the Tricare North Region, to determine what comes next. But in the meantime, the couple paid the bill.
"I don't know what's going to happen, but anything Tricare could do to at least streamline the process for everyone would be good," Traeger said.
In her letter to Congress, Wright said DHA has implemented procedures to enhance the performance of the Tricare regional contractors that handle initial appeals.
"We will continue to closely monitor this process to ensure it is carried out in a manner required by regulation," she said.
