This article has been published in "The Advocate", a monthly publication of the Arizona Association for Justice/Arizona Trial Lawyers Association, May 2006 issue, @2006 by Steven J. Bruzonsky, Esq.
A common question is whether TriCare health care providers can file an ARS 33-931 statutory lien and then balance bill above the amount paid and allowed by TriCare?
Congress established Tricare as the insurance for the medical and behavioral health services for eligible active duty and retired military and their eligible. TriWest is contracted to manage the 21 states West of the Mississippi including Arizona, Hawaii and Alaska. Congress also set the payment schedule at the Medicare Rates and the Tricare payment is called the CMAC (customary and reasonable rate set by Congress.)
Under Tricare, a network contracted facility can only bill the patient for applicable deductible, co-payment or cost share amounts and may not bill for charges exceeding the contract allowed rates. A non-network provider, per Champus Regulations 6010.8-R (32 CFR 199.6-1), who provides services to a TriCare beneficiary, is (1) encouraged to accept assignment of benefits and only bill the patient for applicable deductible, co-payment or cost share amounts and make no attempt to bill the patient for more than the allowed amount; and (2) Federal law prohibits providers who do not accept assignment from billing TriCare patients more than 15% of the Champus maximum allowable charge (CMAC) for any service, and the provider can bill the patient for cost-shares and deductibles.
A health care provider's attempt to bill the patient more than the allowed amount may be a basis for exclusion from the Tricare and Medicare programs. TriWest representatives at 1-888-TRIWEST will verify this and can send letters to providers who violate the above. You can also notify TriCare of the violation on line at http://www.tricare.osd.mil/questions_tma/default.aspx
TriWest Healthcare Alliance manages the healthcare of the Department of Defense in a 21 state West region including Arizona.
TriCare Provider Handbook â€“ West:
Following are pertinent excerpts from TriCare Provider Handbook â€“ West
A network provider is one who serves TRICARE beneficiaries by agreement with the MCSC as a member of the TRICARE Prime network or any other preferred provider network or by any other contractual agreement with the MCSC. A network provider accepts the negotiated rate as payment in full for services rendered.
A non-network provider is one who has no contractual relationship with the MCSC to provide care to TRICARE beneficiaries, but is certified to provide care to TRICARE beneficiaries. A non-network provider must be authorized. There are two types of non-network providers'"participating" and "nonparticipating."
A nonparticipating provider is a certified hospital, institutional provider, physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries, but who has not signed a contract and does not agree to "accept assignment."
Providers who participate in TRICARE, also called "accepting assignment," and who agree to accept the TRICARE-determined allowable cost or charge as the total charge for servicesâ€”also known as the TRICARE allowable charge as the full fee for care. In the case of network providers, the negotiated rate is considered the full fee for care. Non-network, individual providers may participate on a case-by-case basis. Providers may seek applicable copayments, cost-shares, and deductibles from the beneficiary. Hospitals that participate in Medicare must, by law, also participate in TRICARE for inpatient care. For outpatient care, they may or may not participate.