Question:
Tricare Patients, over here!!!

Hey y'all. I had my surgery back in September and everything went great. This is actually about insurance-which I thought I was done with. I have Tricare Prime. They called my surgeon's office with approval for my surgery back in September. My surgeon's office in turn called me. We set the surgery for a week after they recieved my approval. I went in, everything went great, and I've been home for a couple months now. But the past couple days I got two things in the mail: 1) A letter from Tricare that said, "This is not a bill". It went on to show the amount the hospital had charged. Under amount paid, it said "$0.00". For reasons why, it said, "Obesity is not covered" or something. I don't have it in front of me. But that's the gist of it. 2) The first of what I suspect will be many bills from the hospital I had the surgery in. It said that Tricare had not sent either payment nor reason for nonpayment. Amount due: $4,964.87 Like I said, I have a feeling this will be the first of many. My question is this: If my surgeon's office recieved approval for the surgery-and they won't perform it unless you have the money upfront or insurance has approved-then why am I getting bills? Why is Tricare declining to pay now? Has anyone been through this? What should I do? I appreciate any help you may have. This is not the kind of thing you want in the mail before the holidays!    — jenn_jenn (posted on November 24, 2003)

November 23, 2003
Hi I am going through the same thing here... I went out of network and was told everything was covered 100%, well that is 100% of what Tricare would allow. My consults were declined due to obesity not being covered (I asked my doc to resubmit with some comorbs listed) they will now cover a percentage of those. My surgeons bill came to 6k Tricare covered 1500 which I was told the doc has to accept since he takes the coverage but make sure I didnt sign anything that says I would pay the difference. Now as for the hospital bills they only cover a portion of them...I have yet to receive a bill from the hospital and my surgery was 9/3. I know this doesnt answer your question but I just wanted you to know that you are not alone...please feel free to email me if you want more info :)
   — Vegas_ T.

November 23, 2003
I am Tricare Prime too. Here is what I suggest you do... Contact Tricare directly and go over your Explanation of Benefits. If Tricare approved your surgery, and the hospital is a Tricare covered hospital, don't freak over your explanation of benefits. Doc's and hospitals bill standard. Example Room cost is 500.00 a night (just an example here) They bill that to everyone standard. If they have an agreement to accept Tricare patients, they have agreed to receive a certain amount from tricare (usually discounted)lets say 300.00. Tricare will only pay out that amount and the hospital will accept that and you should not receive a bill from the hospital. The other issue could simply be a wrong code from the hospital medical coder. Contact Tricare, they will explain your case specifically. I received bills from the hospital, (because tricare was still processing claim)and still did not owe anyone anything because it was a covered service at a contracted hospital. My other suggestion is to not pay a bill until you have contacted Tricare and find out a true status. I know it can cause panic and confusion especially at this time of year, but hang in there. If your doc received approval to perform the surgery and the hospital is a tricare approved hospital, it should work out nicely for you. 1-800-930-2929 or www.tricare.osd.mil
   — dimpkd

November 24, 2003
Hi, I'm not familiar with TriCare but I used to work for another major provider. If they approved your surgery, they have to pay even if it isn't a covered benefit. First, I hope the doctor got the approval in writing. If he did then send in an appeal with a copy of the approval. If he only got the okay over the phone, did he get some kind of an approval code or number. If not there is still hope, if he has the date of the call, the name of the person he spoke with and an approximate time, most insurances record their calls, even if they can't find it if he has that information you still have a good shot. I agree with the other post, the bill was probably submitted with incorrect coding, your comorbidites should be on the claim as the reason for the surgery, not just obesity. If you still do not get satisfaction from you insurance, write a complaint letter to you state insurance commissioner. They will contact your insurance and demand an explanation and often fine the insurance company if they are in the wrong. Don't let this stress you out. If you followed the rules, this will work out for you. Blessings, Carolyn
   — Carolyn B.

November 24, 2003
Do check for errors. I got that scary bill too and then discovered that when the bill was submitted to tricare, they got one digit on my husbands social security number wrong and that was enough to screw everything up. Also, check with your surgeon and see what date they got approval and if there is an approval number of some sort. They should have something on file. Good luck!!
   — Jennifer H.

November 24, 2003
i have tricare prime too. every single thing was paid for...even the hospital(if you didn't get this paid for in full you should contact your tricare office). a couple of times bills were not paid because they said "obesity is not covered", but if you call your tricare office and explain that is was authorized they will have to use a different code to process it. if you get someone on the phone who doesn't know what they are talking about PLEASE ask to speak with their supervisor this way things can get fixed. another thing that really helps is to print out from online the page that explains your benefits for having wls ....this way you KNOW you are covered for 100%.
   — franbvan

November 25, 2003
Thanks, y'all. I called Tricare this morning and they are indeed covering everything. It was a matter of my surgery date was changed to a week later and they weren't informed. Since the dates didn't match up, they declined to pay. now that they know, all I had to do was call the hospital I had surgery in and they're resubmitting. Tricare will pay for it now. Thanks for all the advice, y'all are great!
   — jenn_jenn