Since new TRICARE contracts went into effect on Jan. 1, there have been widespread complaints about unpaid claims from health providers.
While the administrative contractor for the East region, Humana Military, remained the same, the west region is now administered by TriWest Healthcare Alliance Corporation. Six states (Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin) moved from the East Region to the West Region.
Many providers have stopped seeing TRICARE patients because they are unable to keep their businesses afloat without reimbursement.
According to Austin Carrigg, CEO of Exceptional Families of the Military, a nonprofit organization that supports military families with complex medical needs, much of the confusion stems from a glitch in the systems of Palmetto Government Benefits Administrator (PGBA).
PGBA is a subcontractor for Humana Military and TriWest Healthcare Alliance Corporation that became the claims processor this year. Carrigg said she was told by PGBA that some accounts have been marked with placeholders indicating they have other health insurance that should pay for services before TRICARE. The placeholder must manually be removed for each claim.
PGBA did not respond to requests for comment, and the Defense Health Agency (DHA) was unable to comment before this article went to press. But a spokesperson for Humana Military told NBC in May that the root cause of the issue had been identified and the majority of the incorrect data had been fixed.
“We take our commitment to TRICARE East Region beneficiaries and providers very seriously,” the spokesperson said, “and apologize for the inconvenience and frustration this problem has caused.”
Carrigg said these “hiccups” could have been resolved between providers, TRICARE and DHA “without doing what they’ve done to families.”
There were also frustrations among military families after TRICARE pharmacy benefit management changed hands in 2024 to Express Scripts.
Accredo, the specialty pharmacy in the Express Scripts network, handles mail order medications for many high-cost prescriptions that require careful handling. But families report delays in receiving their medications, many of which are damaged without consistent refrigeration. They also no longer have access to nurses to provide in-home support, the way they did when using local pharmacies.
Carrigg said the struggles for military families with complex medical needs are getting harder with time.
“But we can’t fully blame DHA,” she said. “We also have members of Congress who are making laws and making changes but not living our lives and not realizing the ramifications.”
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