Thinking Collection Agency for a Beneficiary Claim?

TRICARE strives to process and complete provider claims as quickly and accurately as possible. The Military Health System can be complex, however, which can occasionally lead to claims submission mistakes or oversights that result in unpaid claims and ultimately patient billing. It is important for providers and their staff to learn claim submission pitfalls and avoid sending unpaid beneficiary claims to a costly collection agency.

“In a majority of cases involving unpaid claims, there has been an error in processing or incorrect information has been given about the beneficiary,” says Marcia Bonifas, deputy director, TRICARE Communications and Customer Service. “It is important to work with the claims processor and the beneficiary first to find out what is wrong and why the claim wasn’t processed. Most of the issues can be resolved in this first step.”

Quality, hassle-free medical care for themselves and their families is important to service members’ peace of mind, as well as the uniformed services’ broader goals of recruiting and retaining qualified personnel. Far too often service members must shoulder the burden of incorrectly processed claims, which causes them great concern and distracts them from their tasks at hand.

To ease beneficiaries’ burden and assist them in understanding and resolving claims issues, TRICARE staffs Debt Collection Assistance Officers (DCAOs) at each TRICARE Regional Office (TRO) and military treatment facility (MTF). The DCAO helps beneficiaries in determining the validity of collection agent claims or negative credit reports received for debts incurred as a result of health care under TRICARE. After researching the beneficiary’s claim with the appropriate claims processor or other agency points of contact, the DCAO provides the beneficiary with a written resolution to the collection problem and notifies the collection agency that action is being taken to resolve the issue.

The most important action you can take for your practice and for TRICARE beneficiaries is to avoid the debt collection process altogether. By following these simple error-checking steps, you can help prevent the need to pursue debt collection.

1. Review the TRICARE explanation of benefits (EOB) statement when it arrives; if a claim is rejected, it will state the reason why.
2. If the EOB states that inaccurate beneficiary information is the reason for the denial, it is important to make every attempt to contact the beneficiary to obtain the correct information.
3. If an EOB does not arrive within 45 days, this may mean that there has been a problem in submission of the claim. Contact your TRICARE regional contractor, TriWest, or if the patient has Medicare, contact the TRICARE dual-eligible fiscal intermediary,Wisconsin Physicians Service (WPS), at 1-866-773-0404.
4. Contact TriWest if you have additional or corrected information regarding a rejected claim.

“It’s important for providers to read and understand the explanation of benefits. It’s critical to resolving claims issues before they become debt collection issues,” Bonifas says. “An overwhelming majority of claims issues could be solved with the explanation of benefits.”

Many times claims are rejected because of mistakes made in entering the following common information. Awareness of these common mistakes can decrease the likelihood that they will occur and increase the likelihood that your claims are more accurately processed in a timely manner.

Service members move often or are in transit. It’s common for providers to have an old or temporary address on file. Ask beneficiaries to update their information during each visit.

Typing errors and other factors can cause a wrong SSN. Always double-check the SSN with the beneficiary. Make sure to use the sponsor’s SSN, even if the beneficiary being treated is not the sponsor. (Exception: TRICARE-eligible unremarried former spouses provide their own SSN rather than their sponsor’s.)

Providers should enter the most current procedure and diagnosis codes on claims and confirm coverage before performing a procedure. If there are any questions whether a service is a TRICARE-covered benefit, contact TriWest at 1-888-TRIWEST for assistance.

Many times beneficiaries are not aware of or simply forget the copayment. Care should be taken to make the beneficiary aware of the copayment at the time of treatment to avoid problems. Active duty service members and TRICARE Prime active duty families have no copayment. Network and non-network providers who accept assignment cannot charge the beneficiary more than the patient responsibility.

TriWest, assists providers with claims questions and problems through a claims priority unit. Contact the unit before initiating any collection action against a TRICARE beneficiary. Call 1-888-TRIWEST for more information about contacting a claims priority unit representative.

More information on claims submission requirements can be found in your TRICARE Provider Handbook or online at www.triwest.com. TriWest also offers provider training, workshops and briefings throughout the West Region. You can find more information about these educational opportunities online.