Report: Tricare Appeals Taking a Year

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While Navy Cmdr. Cassidy Norman navigates the murky waters of the Tricare coverage appeals process, the bills pile-up for his 4-year-old son's Attention Deficit Hyperactivity Disorder therapy.

Chace Norman was diagnosed with ADHD last year. The therapy, which costs about $7,000 a year, helps him have normal social interactions in his special needs preschool. Without it, his parents worry that he will be kicked out of class. But because Chace was initially assessed as having a sensory disorder and Tricare does not cover "sensory integration therapy," the agency denied their claim, Norman said.

"It appears to us on the outside that there is great internal pressure to save money," Norman said. "I understand the policies and I understand that they're an insurance company. But to any reasonable person and any court of law, their argument would not pan out."

The Normans are among the 9,246 beneficiaries that moved through at least some part of the Tricare appeals process last year. And a new report from Tricare detailing that process reveals they could be there a while.

The report, sent to lawmakers June 4 in response to a congressional mandate, showed it takes an average of almost a year for Tricare users who go through the entire appeals process to get a final ruling on whether the agency will pay for a non-emergency procedure or treatment like Chace's ruled not medically necessary or against policy. 

According to the report, the 124 Tricare users who appealed a coverage decision all the way to the final step -- a hearing -- between 2009 and 2013 received answers an average of about 346 days after their initial appeals. 

When coverage is denied, the report says, users can appeal to three different levels. After the last appeal level -- a hearing during which witnesses can be called, agency officials make a final decision based on the advice of the hearing officer. But in some cases, according to the report, the hearing official's recommendation for payment is put aside and payment is still denied.

Military healthcare advocates called Tricare's ability to simply overturn a hearing officer's decision potentially "arbitrary." They said the process is not user friendly because, in part, there is no easy way for users to track their appeals. The lack of clarity on how decisions are made combined with the length of the appeals process is unacceptable, they said.

"One thing that is glaring and we cannot understand, is the length of time to get a decision," said Karen Golden, MOAA's deputy director of government relations and military family issues. "It's frustrating for our families, it's frustrating for advocates and the system is not transparent. What this report to Congress shows is that this is a bunch of gobbledygook, for lack a better word."

Fort Carson-based Army spouse Judy Davis agrees. When her 19-year-old son, Geoffery, became suicidal while attending Texas Tech University in 2012, he checked himself into a mental health program at the school and was placed under suicide watch.

But Tricare region South officials told her that the university's program wasn't covered. Instead, she said they told him to travel over two hours away to the closest in-network facility. And because he was currently under a suicide watch and not actively a threat when Davis spoke to him about his care, they tagged his file as not being at risk of harming himself, even though he would have to be released and in harm's way to make the trip.

"My son wouldn't be here if I had listened to Tricare. And I wasn't willing to take that risk," Davis said.

So instead, she chose to appeal the decision and leave her son in the 10 week in-patient program. And even after going through the appeals process, they still denied her almost $40,000 claim.

Davis said the report again shows just how broken the appeals process is. But fixing it, she said, should start with making the process of getting care easier to understand.

"What I would do, first and foremost, is some kind of step-by-step on how to get your dependent the care they need," she said. "Too often, the person who is your first contact on the phone with Tricare does not have a clue. They know how to read a screen and say this is the policy. Well, awesome, this the policy -- but my son is in crisis. What do I do?"

Tricare's website does contain fact sheets and instructions for using the policies, including one on how to work through the appeals process. But Davis said she did not know about them, and none of the Tricare representatives she spoke with told her about them.

Tricare officials, however, said they provide several systems to make the process transparent. For example, they said Tricare North, managed by Health Net, uses an online appeal application that allows users to both file their appeal and follow up on its status.

"All of the Tricare contractors provide contact information to beneficiaries and providers for filing appeals and following up on appeals after filing," they said in a statement. "Defense Health Agency appeals sends acknowledgment letters to all appealing parties with a contact address and telephone number, and appealing parties routinely contact that office to check on the status of their appeal."

Kathy Beasley, MOAA's deputy director of government relations for military healthcare issues, said she believes the appeals system needs major fixes, starting with simplification. Families who have chronic health conditions or special-needs children are the most likely to be involved in the appeals process, she said, and simply don't have time to sit and figure it out.

"There are people who have dropped out of this process because it's been so laborious," Beasley said. "Military families, who are probably moving around, have got to manage this kind of thing?"

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