WASHINGTON, D.C. (July 16, 2019)—Changes to the TRICARE regions to consolidate to two plans from the previous three plans have been fraught with provider network and claims processing issues. While AAHomecare has been contacted regarding these issues with both regions, the bulk of the issues have been with the TRICARE East contractor, Humana Military. Providers have reported delays in being added to the Humana Military network, long delays in claims payments, incorrect rate payments and improper claim denials. Some providers have reported 94% of claims denying and payment delays of more than 180 days. During this time, Humana Military also implemented a new claims processor with Wisconsin Physician Services (WPS).
AAHomecare's Vice President of Payer Relations Laura Williard, and Director of Payer Relations David Chandler were able to meet with executive leadership at Humana Military and leadership from WPS to discuss these ongoing issues. The most problematic issue is Humana Military's requirement that providers submit medical documentation with every claim, even though the WPS claims system has not had the ability to connect this documentation to the claims. When the documentation is received with the claim, it must be indexed into the WPS system and be available when the claim is processed.
With the volume of documentation being received, the indexing of these items has been in a backlog situation and is creating inaccurate claim denials per Humana leadership. They are aware of this issue and have implemented the following fixes:
- Claims are currently being put into a suspended status in lieu of being denied.
- Daily these claims automatically check for documentation and will pay when that documentation is available.
- Management of documentation indexing and claims processing have been combined.
- There is a current project underway that should be completed by the end of July to bring the indexing of medical documentation up to date. They have also assured us that once this occurs that they can handle the volume of documentation being received daily, which will eliminate the claims suspension and denials.
AAHomecare's Williard and Chandler have requested that Humana Military waive the requirement for documentation submission with each subsequent rental month after the initial documentation is received for the service. The contractor is currently evaluating this request.
AAHomecare has also become aware of instances of incorrect payment amounts being paid for specific services. AAHomecare will continue to meet with Humana Military on behalf of the industry to ensure these issues are resolved. We will also be looking into specific mandates with the Defense Health Agency that require additional work for the providers and the contractors to identify ways of streamlining the process to ensure the best care for our military personnel and their families.
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