Tricare problems

1000words · 05-28-2008, 04:44 PM

So... I got my referral, then my approval and then a surgery date. I was going to be the first tricare Lap Band patient at the hospital.

I went for my pre-op today and a bomb was dropped on me. Apparently the hospital checked with tricare and found out how little they would pay and have decided not to take my insurance. Both the hospital and the doctor accept Tricare... but have decided not to take it for the Lap Band.

I feel a bit betrayed, by the hospital... but I do understand since apparently Tricare would only pay about $850 over the cost of the Lap Band. But, I wish they would have figured this out a few months ago before they led me along.

So, I am now shopping for a new surgeon. My surgery was scheduled for June 9... I will be lucky to get in to see a new surgeon by that date.

Does anyone who have Tricare have a copy of their explanation of benefits of what was actually paid for the surgery?

Stay_Tuned · 05-28-2008, 04:52 PM

OMG!! I have never heard of such a thing! To just decide not to do a surgery on a patient that is approved with an insurance they take... Is that even allowed??

I have tricare and was banded a week ago... I will let you know what they pay as soon as I get my EOB....

Can you fight this at all??

heyliberrylady · 05-28-2008, 05:00 PM

I have tricare...I paid $250 copay for the hospital and $4,550 to my surgeon.But tricare is reimbursing me $3,500 for that. I also paid $245 for my first initial Dr visit and I got $137 of that back...My Dr was out of network so they had to write my up as self pay and then Tricare did my reinbursments...I didnt have any problems...they approved me in 2 days and I had my surgery the next week....

1000words · 05-28-2008, 05:04 PM

Apparently there is nothing I can do. I spoke to Tricare and a hospital or doctor can decide at any time that they do not want to do a procedure. Basically, they can not be forced to lose money.

I went as high as the CFO at the hospital. We agreed that he would submit the codes to tricare to get an official amount of what would be paid. I know it will be less than he wants.

The truly rude thing is that I found all this out when I went in for my pre-op appointment today and they asked me to sign a bunch of forms. Instead of having the usual form that you sign saying you will pay if your insurance does not pay... it was a form that said that I would bay the BALANCE after my insurance pays. I called Tricare and they said that although balance billing is not allowed, that if I sign the form I am waiving that protection. The bitchy lady actually told me that it was cosmetic surgery and the hospital was not going to take the finacial liability on that... and then told me that most people pay for the surgery.

That was followed by two hours of sitting in the hospital hallway upset while my surgeon, the obesity nurse coordinator and the CFO met.

The whole day was bad, bad, bad. I am still sick to my stomach. I have been on the pre-op diet for three weeks now and wondering if I should continue.

Stay_Tuned · 05-28-2008, 05:53 PM

Gosh I hope I didnt sign that paper.... They told me to sign this paper that allowed them to treat me... That was it... Hmmmmm Well I guess we will see if I get bills...

As down as I am sure this has you.... I would try your hardest to stay the course.... Keep on keepin on with your pre op diet... Don't let some money hungry hospital stop you from your ultimate goal of life long health....

You can do it! Full speed ahead... and just think... If you find the right surgeon..... You will be ready for his first available... even if they say how about tomorrow!

IntoLess · 05-28-2008, 06:07 PM

Instead of calling Tricare, since you never know what moron you will get, go to your local Tricare office. make sure you take with you your letter of approval, OR your approval number. As far as I know, the hospital has contracted ALL services provided with the insurance companies, whoever they may be, and have both parties AGREED with these terms and stipulations before entering into the contract. You cannot be turned down by the hospital, the surgeon, I am not sure about.
As far as you being billed, as a Tricare Prime beneficiary, you are not supposed to be billed for anything. The insurance form you sign that says they will bill you for what Tricare doesn't pay, is a standard insurance form. As a Tricare STANDARD beneficiary you can be billed for part of the difference, I believe. IF as a PRIME beneficiary you are billed and asked to pay a difference, take the bill to your local Tricare Service Center and they will take care of it.

corry1 · 05-28-2008, 06:07 PM

I was banded with tricare on April 3rd. I paid $500 total to my dr. The claim is still in process, but everything looks ok so far. I will keep you posted.

1000words · 05-28-2008, 07:02 PM

kitty- I know what form you are talking about... but this was NOT the standard pay if your insurance doesn't form. It was explained to me by both the hospital and a patient advocate at the Tricare Service Center that if I signed that form I would be giving up my rights not to be billed for the remainder of the bill that Tricare does not pay. I said I would be willing and required to pay the balance that my insurance does not pay. According to someone at Tricare this is a way a lot of hospitals get away with coming after Tricare patients... the form basically screws the patient over.

Apparently any doctor can refuse to do an elective procedure if they do not believe Tricare will pay enough... they can not be forced even if they are a Tricare provider.

IntoLess · 05-28-2008, 07:36 PM

After 20 million surgeries (okay a bit extreme, maybe 10), all elective I have never run across a form like that, I have always been given the standard form.
I just do not understand your doctor. Surely you aren't his FIRST EVER Tricare patient. I know you are the first for the band, but he has had some dealing with Tricare before you and he knew they wouldn't cover very much of the costs. I looked at my claims sheet the other day and of the $15000 it cost for my sinus surgery (hospital, doctor, anesthesiologist, etc.), Tricare paid about $4000 of it. The doctor didn't have to do it, as it was elective, but boy am I glad he did, I haven't breathed this well in years! It is no wonder fewer and fewer places are accepting Tricare, and we (dependents) pay the price for it.

Keleka · 05-28-2008, 10:06 PM

I'm really sorry to hear this about your surgery~ Hopefully things will work out for the best!

I too am concerned about the whole TriCare thing! I have TPR and have a referral to see the Surgeon for evaluation. The problem is he isn't in network but accepts Tricare. Now as TPR this could mean a couple of things: 1 - I will be responsible for $300 deductible and 50% of costs. 2- Maybe since there isn't an in-network provider TriCare will cover it at 100% The one good thing is when I go to his informational seminar (I have to go this first before scheduling an apt) They make copies of insurance cards and call the insurance company to see what exactly is covered. So I should know up front what I will be responsible for.

Any other TriCare information anyone has would be great!

1000words · 05-28-2008, 11:12 PM

I guess I worded things wrong... it is not the doctor that is the problem, it is the hospital. The doctor said he would do the surgery for free... but the hospital is not willing to budge on their minimum acceptable amount.

I wish I would have found this out months ago so I wouldn't have bothered with this program and went ahead with an established tricare Lap Band provider.

gina s. · 05-28-2008, 11:19 PM

Wow.....that sucks. Hope you find an alternitive soon.

Cadets71 · 05-29-2008, 12:04 AM

I am so sorry to hear this! I had a negative experience here in Las Vegas - the largest practice for lap band surgery will only take 1 Tricare patient per month because "Tricare pays too little". And this practice is the preferred provider for lap bands! I was so angry about their discrimination that I called the manager of the Tricare Provider Relations department. Apparently they can do this. However, I don't believe that the practice would like to see Headlines in the local paper that they are discriminating against military families! I think what your hospital is doing is very discriminatory. Wonder if that CEO/CFO would like to see an editorial on the local news!!

I will keep you in my thoughts and hope that you can find a more reasonable hospital. Does your surgeon practice anywhere else? I don't know where you live but I hope you are in an area with more choices. Good luck!

woodbox20 · 05-29-2008, 12:40 AM

Wow too bad you can't come to Alaska and have your band done. I was so Nervous that I was going to have issues with Tricare but I didn't. Before we were stationed here we were in Massachusetts and I was going to have the procedure done there and tricare gave me the hardest time ever. Unfortunately I didn't have the surgery due to pregnacy and then a miscarriage and then PCSing to Alaska.
Well, one year after being here I became pregnant and 1 year later I decided I wanted to have the band done. I thought I would have to wait months to have the procedure done. I decided to see a doc in March about it, I was banded on April 10th. I couldn't believe it!!!! The only issue I had with Tricare is they sent me an approval letter for the surgery and then when my docs office called to confirm it they said it was denied. But they then said it was because of insufficent information, that my doctors office took care of.
I was really shocked that things went so smoothly and here in AK of all places. Trust me AK has been a miracle state for me. Long story...

Anywho, I received my bill. Now I have Tricare prime, but the total cost of the surgery was $25,256. They adjusted it (which I don't understand what that means) to $17,504 and then the insurance claims outstanding $7,751.75. I'm not quite sure what that all means. Did tricare pay the 17,000 or the 7,700? Either way they paid for it and I am so happy for that :biggrin2:!

Fdiljn · 05-29-2008, 08:49 AM

Kitty I think you are a little out of line when you call the workers at Tricare "morons" Like most of us most of them know what they are doing and work very hard to do the best for us. In every walk of life there are those who just get by and at times we have to deal with that. Tricare may not be the best insurance but it is what we have and it is our choice whether or not to use it.