tricare and referral after 'in-network' providers have refused care

[elus0814]

For the past few weeks I've been trying to get tricare to give me a referral for my homebirth midwife. I'm on prime and she's an "out of network" provider. I will go to her anyway, even if it means switching to standard, but I really don't want to do that and be locked into it for another year (I had to do it in another state to get a midwife last year). The tricare office here and the people at the 1-800 number keep refusing to give me a referral for someone out of network. I even brought my letter from my backup practice (that has two of the three in-network midwives) that says they are refusing to treat me. They wouldn't put in the referral since there is one other in-network midwife. I called this last midwife and the practice she is with is sending me a letter saying they are refusing to see me at all (I explained the situation to her and she said they wouldn't be willing to 'play backup' either).

My question is:

Should I be given my referral to see an out-of-network midwife now that all the in-network midwives are refusing to see me?

Are they going to try and say I have to see an ob for it to be covered with prime?

Do I have any recourse should the awful tricare office lady here on base refuse to put it in again?

Should I just suck it up and switch to standard and pay the 20% out of pocket and lose the ability to be seen on base? (I really like my on base doc and it's easy to just drive down the street and go there for free)

[~Katie~]

I can't give advice for your situation but if you want to post this in Finding Your Tribe in the Military Moms group there should be plenty of people to answer it for you.

[luv-my-boys]

Dont give up. We had a similar situation but not ob/gyn related. We are tricare prime as well and they kept trying to send Ds to "in network" providers but the thing is hald didnt see children and the other half didnt take new patients. We had to appeal to tricare because they have to find you a provider (in network or not) within a geographically reasonable area unless is an extreme specialty (like only this 1 doctor does this kinda thing)

Our pcm really backed us up though with resubmitting the referrals and a letter of explanation on why we had to see this person. so gather every denial letter you can as well as names of people you speak to in each "in network" office and submit that to them. in our case it took a few weeks but they finally approved the referral and paid it. Also is your midwife willing to accept tricare payment or will she balance bill you the remaining portion? I found that once the dr's office submitted a letter stating that they would accept tricare pymt that it went a whole lot smoother. but thats the whole point of Tricare prime.

as for the ob/gyn they probably will tell you to go see one instead but hold still. As long as your pcm is putting in a referral for a midwife thats not a question at that point your batting the provider they will approve not the "speciality care"

[mntnmom]

If you're an active duty spouse, as far as I know, you can still be seen on post if you switch to standard. We're overseas, so it may be different. But talk to your tricare rep to be sure. In my situation it only applies to the possibility of needing to be seen off post. If there is an emergency and I have to been seen at a civilian hospital for instance, I'll might have to pay some out of pocket costs.
As for your question about referrals, I wish I knew. We couldn't get a referral from the MTF, so I just switched to standard.

[nia82]

I thought you can only see out of network providers if you switch to Standard. An acquaintance did that for her homebirth and Tricare reimbursed $1500 for her homebirth midwife. However, your midwife has to be a CNM. Tricare WILL NEVER give even a penny for CPMs or LMs.

[elus0814]

Originally Posted by luv-my-boys

Dont give up. We had a similar situation but not ob/gyn related. We are tricare prime as well and they kept trying to send Ds to "in network" providers but the thing is hald didnt see children and the other half didnt take new patients. We had to appeal to tricare because they have to find you a provider (in network or not) within a geographically reasonable area unless is an extreme specialty (like only this 1 doctor does this kinda thing)

Our pcm really backed us up though with resubmitting the referrals and a letter of explanation on why we had to see this person. so gather every denial letter you can as well as names of people you speak to in each "in network" office and submit that to them. in our case it took a few weeks but they finally approved the referral and paid it. Also is your midwife willing to accept tricare payment or will she balance bill you the remaining portion? I found that once the dr's office submitted a letter stating that they would accept tricare pymt that it went a whole lot smoother. but thats the whole point of Tricare prime.

as for the ob/gyn they probably will tell you to go see one instead but hold still. As long as your pcm is putting in a referral for a midwife thats not a question at that point your batting the provider they will approve not the "speciality care"

It's actually ILLEGAL for a patient on tricare to be 'balanced billed'. It's the same law that applies to medicare/medicaid. Balance billing is illegal in this situation. If anyone tries to balance bill you take the bill to the tricare office and they should straighten it out for you.

The hb midwife I want to see is a tricare provider and will accept their payment but she is about 70 miles away and so is 'out of network' for me, if I lived closer to her she would be 'in network'.

[elus0814]

Originally Posted by mntnmom

If you're an active duty spouse, as far as I know, you can still be seen on post if you switch to standard. We're overseas, so it may be different. But talk to your tricare rep to be sure. In my situation it only applies to the possibility of needing to be seen off post. If there is an emergency and I have to been seen at a civilian hospital for instance, I'll might have to pay some out of pocket costs.
As for your question about referrals, I wish I knew. We couldn't get a referral from the MTF, so I just switched to standard.

Technically you can be seen on base if you are on standard but you are at the bottom of the list for getting an appointment, meaning if there are no prime people or retirees then they can offer you an appointment. I've been on standard before and I was never able to get an appointment on base since everything would be booked up by prime people as soon as the appointments opened up.

[elus0814]

Originally Posted by nia82

I thought you can only see out of network providers if you switch to Standard. An acquaintance did that for her homebirth and Tricare reimbursed $1500 for her homebirth midwife. However, your midwife has to be a CNM. Tricare WILL NEVER give even a penny for CPMs or LMs.

The midwife is a cnm. You can be seen by an out of network provider while on prime if there are no in network providers available. I can't figure out if they are going to go along with 'there are no in network providers' because they may lump midwives in with obs.

My understanding of it from the midwife is that tricare will not pay for the homebirth but they pay so much for the prenatal care that it is the same amount as her 'out of pocket/no insurance' fee so there is nothing left to pay. She has lots of tricare patients and even showed me a bill with the name blanked out because I couldn't believe tricare really paid it all after being told by the tricare office that tricare wouldn't 'pay for a homebirth'.

[mbhf]

Originally Posted by elus0814

It's actually ILLEGAL for a patient on tricare to be 'balanced billed'. It's the same law that applies to medicare/medicaid. Balance billing is illegal in this situation. If anyone tries to balance bill you take the bill to the tricare office and they should straighten it out for you.

The hb midwife I want to see is a tricare provider and will accept their payment but she is about 70 miles away and so is 'out of network' for me, if I lived closer to her she would be 'in network'.

Yes, it is illegal, but the midwife doesn't have to accept tricare payment period and her accepting what tricare pays is generally a big favor to the client who otherwise would have to pay the entire fee. One of my hm MWs was a CNM and she jumped through Tricare's hoops to get partial payment on my behalf and I can't imagine telling her I wouldn't pay the balance that Tricare did not cover. It is my choice to homebirth, with or without insurance coverage for it, and if I can get tricare to pay for part of it great, but I can't imagine just telling my midwife after the fact that she's out several thousand dollars because she jumped through my insurance hoops to save me $3500.

[elus0814]

Originally Posted by mbhf

Yes, it is illegal, but the midwife doesn't have to accept tricare payment period and her accepting what tricare pays is generally a big favor to the client who otherwise would have to pay the entire fee. One of my hm MWs was a CNM and she jumped through Tricare's hoops to get partial payment on my behalf and I can't imagine telling her I wouldn't pay the balance that Tricare did not cover. It is my choice to homebirth, with or without insurance coverage for it, and if I can get tricare to pay for part of it great, but I can't imagine just telling my midwife after the fact that she's out several thousand dollars because she jumped through my insurance hoops to save me $3500.

Anyone can always choose to pay extra but what I'm saying is that you cannot be forced to. No provider can require you to pay the balance between what tricare allows and what they want, that is illegal.

[jorona]

Originally Posted by mbhf

Yes, it is illegal, but the midwife doesn't have to accept tricare payment period and her accepting what tricare pays is generally a big favor to the client who otherwise would have to pay the entire fee. One of my hm MWs was a CNM and she jumped through Tricare's hoops to get partial payment on my behalf and I can't imagine telling her I wouldn't pay the balance that Tricare did not cover. It is my choice to homebirth, with or without insurance coverage for it, and if I can get tricare to pay for part of it great, but I can't imagine just telling my midwife after the fact that she's out several thousand dollars because she jumped through my insurance hoops to save me $3500.

Ditto to this along with added info. I switched to Standard in order to get a larger Tricare payment for my midwife who is actually not even a CNM or in-network. She's a CPM and what Tricare considers a "Tricare certified provider", meaning she has not agreed to accept the Tricare maximum allowable charge for her services or be a contracted provider for them. As it was explained to me (and as I understand it from the online literature) it is completely legal for her to receive the balance of her payment from me - which I am happy to give her because she's already saving me $1400 for billing Tricare in the first place.

I can still see PCMs on base but Standard patients have last priority. And here it's hard enough to get an appointment even when you're on Prime, so you can forget it if you're on Standard. I didn't like my PCM anyway so it didn't break my heart to leave Prime.

[elus0814]

Originally Posted by jorona

Ditto to this along with added info. I switched to Standard in order to get a larger Tricare payment for my midwife who is actually not even a CNM or in-network. She's a CPM and what Tricare considers a "Tricare certified provider", meaning she has not agreed to accept the Tricare maximum allowable charge for her services or be a contracted provider for them. As it was explained to me (and as I understand it from the online literature) it is completely legal for her to receive the balance of her payment from me - which I am happy to give her because she's already saving me $1400 for billing Tricare in the first place.

I can still see PCMs on base but Standard patients have last priority. And here it's hard enough to get an appointment even when you're on Prime, so you can forget it if you're on Standard. I didn't like my PCM anyway so it didn't break my heart to leave Prime.

It is not legal for her to balance bill you. She can, however, bill you for up to 15% above the tricare allowable charge. That is the maximum legal amount you can be charged. You can agree to pay more but that is you doing it because you want to, not because the provider is allowed to. I am getting this information off of a policy printout from the tricare office. I had brought up to them that I was being balanced billed by an ER doctor and all they had to do was call the hospital to remind them that the medicare/medicaid law applies to tricare since it is a government benefit and not insurance.

A midwife that bills tricare for you is not "saving $1400", as you say, she is just doing paperwork for you which you could have done yourself. It does not matter if the provider has agreed to accept the maximum allowable charge or not. If they do not agree then they can charge more than the maximum allowable charge but the most they can charge is 15% over the maximum allowable charge. That is the most they can legally charge any tricare beneficiary, prime or standard. If a provider is trying to balance bill you or charge you more than 15% over the tricare maximum allowable fee you should notify your tricare office or call the tricare 800 number. The law that covers this is the same as for the medicare/medicaid benefit and applies to all providers that accept as patients recipients of government benefits.

[Plummeting]

You should eventually be able to get a network exception for an out of network midwife. Tricare does not lump midwives and OBs into one group, fortunately. I'm seeing an out of network CNM on a referral in an area with about 100 (literally) in network OB's.

Originally Posted by jorona

Ditto to this along with added info. I switched to Standard in order to get a larger Tricare payment for my midwife who is actually not even a CNM or in-network. She's a CPM and what Tricare considers a "Tricare certified provider", meaning she has not agreed to accept the Tricare maximum allowable charge for her services or be a contracted provider for them.

The amount Tricare will pay is not more if you're on Standard. The maximum allowable charge is the same, no matter which plan you're on. When you switch to standard, it just means that you have a cost share and can see out of network providers without a referral. It doesn't increase the Tricare payment to your midwife.

Additionally, CPM's are not and never have been considered certified providers. You lucked out in that someone made a mistake and is letting her slip through the cracks. CPM's are specifically excluded from Tricare coverage because they aren't certified providers. Sometimes they get approved, but it's purely by accident. (Which I think is crap, but that's not the point.)

Originally Posted by elus0814

My understanding of it from the midwife is that tricare will not pay for the homebirth but they pay so much for the prenatal care that it is the same amount as her 'out of pocket/no insurance' fee so there is nothing left to pay. She has lots of tricare patients and even showed me a bill with the name blanked out because I couldn't believe tricare really paid it all after being told by the tricare office that tricare wouldn't 'pay for a homebirth'.

But your midwife and the Tricare people are BOTH wrong in this case. Tricare absolutely pays for home births. Your midwife may not be aware of how to collect from Tricare properly. Some of the out of network providers aren't. The way Tricare prenatal referrals are issued is as a certain number of office visits (it's 18) rather than as global maternity care. The reason for that is that women on Tricare have a tendency to move in the middle of their pregnancies. If your midwife wants to be paid for the birth, she has to call the 800# on your referral and tell Tricare where the birth is supposed to happen and what your EDD is. Once she does that, they'll change the referral from 18 office visits to global maternity care, and she'll be reimbursed for the birth. Other insurance companies don't do it that way, but Tricare does because women on Tricare are highly mobile, for obvious reasons. Tricare doesn't pay or not pay based on where the birth happens, but lots of Tricare people don't know what they're talking about, so you can't rely on them to know that. Heck, when I was getting my referral worked out for this pregnancy, I had the Tricare woman on base insisting Tricare didn't cover midwives and refusing to even look in her system. Ten minutes after I started arguing with her, she finally looked and, of course, CNM's were in there. Duh.