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By Lynn Stuter
July 11, 2012

With the recent Supreme Court decision, concerning Obamacare, some think they've gotten a great deal via this decision. Mostly, these people fall into the "entitlement" crowd—people who believe the government should take care of them.

The rest think they've gotten a rotten deal, one bought into by the feckless Republicans who don't have the cojones to stand on their feet and fight. Most remember the words of Madam Pe-lousi: "we have to pass the health care bill so that you can find out what is in it …" While the current speaker - "Boner" - claims he's going to repeal it, talk is cheap (and, obviously, so is he)!

Many in this country today, being active duty military or retired, have government provided healthcare insurance, something known as TriCare.

After years of having no contact with TriCare whatsoever, let me give readers a bit of insight into my recent skirmishes with TriCare. When you finish reading this venture into the absolutely mind-boggling, ask yourself how Obamacare is going to be any better.

In early April 2012, I discovered that TriCare is considered a secondary insurance if you are retired military and you have other healthcare insurance, termed by TriCare as an OHI.

Since my husband and I both have had major surgery in the last year, I called TriWest, the TriCare contractor for the western region of the United States. I asked them what I needed to submit to receive reimbursement for medical expenses not covered by our OHI. I was told, by a TriWest employee, that all I needed to do was to submit Form DD 2642 and the explanation of benefits (EOB) received from our OHI. This I did. At the time, I enquired about the itemized billings from the providers, and was told those weren't needed.

TriWest received appropriately filled out and signed Forms DD 2642 for both my husband and myself, along with the requisite original EOBs attached, on April 10, 2012.

Although subsequent inquires, on April 16 and 23, netted no indication of where these claims were, on April 30/May 1, 2012, we got them back; not the originals we had sent, but copies, and poor copies at that. Enclosed were letters making various untrue claims, such as claiming the EOBs didn't show the name of the beneficiary (they did, every one of them), and stating the itemized billings were missing.

On April 30, 2012, I called TriWest, asked them what else was required for them to pay these claims. Nothing else was disclosed as required except I was told that, in the case of the hospital bill, a Form UB-04 was required.

I gathered together all the required information and sent it to TriWest on May 4, 2012; TriWest received it on May 7, 2012.

My understanding of what happens, when a beneficiary (the patient) sends in a claim, is as follows: the documents are scanned in to the TriWest system (whatever that system is) in the TriWest mail room. What is done with the original documents after they are scanned in? No one at TriWest has been able to answer that question; and believe me, I've asked.

Now supposedly, TriWest has 30 days from the date of receiving a claim to process it. That seems pretty straight forward, right? Guess again. It's all in the semantics, folks. The date of receiving a claim isn't really the date they receive it; it seems to be whatever date they happen to want it to be. The claims TriWest received on May 7, 2012, they claim they got on May 17, 2012. Figure that one out!

And what does process mean? In their own words, the following supposedly defines process:

When a claim is processed, it is input into the system and will be processed according to various edits, which could be is there primary insurance, is this a network or non-network provider, is this a payable diagnosis, or procedure code, does this require a prior authorization and so forth. Once all edits have been resolved the claim can be processed for payment.

Got that? Good.

Now comes the kicker. Every time a claim doesn't pass an edit, it is kicked out, maybe removed, maybe denied. And when that happens, the claim is in limbo until the required information is received. Then the claim is given a new claim number and the 30 day clock starts all over again. With this knowledge, go back and read their definition of process. Isn't very accurate, is it?

Great way to run a railroad, wouldn't you say? Every nit-pick thing that can cause a claim to fail an edit lengthens the time a claim is held, unpaid, in the TriWest system. And the longer that claim is held, for whatever reason, the more money TriWest stands to make from their Department of Defense (DoD) contract.

Here are some of lame excuses for why our claims have been denied/removed:

Missing POA code on Form UB-04. TriWest must know that the condition for which the medical procedure was performed was "present on admission" to the hospital. My immediate reaction to this stupidity was to quip, "nah, we just thought having surgery would be a good thing to do; and since the doctor was at the hospital that day, we availed ourselves of the opportunity!"

Were we told the POA code was required before submitting the bills? No. Why not? We've asked; no answer!

Was the itemized billing for the hospital checked, when TriWest received the itemized billing, on May 7, 2012, to make sure the POA code was there? No. Why not? We've asked; the answer was that such things aren’t checked for until the claim is processed.

TriWest denied this claim on June 11, 2012, one month after receiving the itemized billing, because of the missing POA code. The following day, June 12, 2012, the hospital sent the claim directly to TriWest. Today, almost one month later, TriWest has still not entered this claim on their system!

Missing itemized billing. TriWest lost the itemized billing for a provider, denied losing it; but could not produce the original documents scanned into the system in their mail room. The itemized billing was there when the claims were stapled to the back of the Form DD 2642. Quite obviously, the billing was also there when TriWest received the claims. Given the incompetence and inefficiency of TriWest, what happened to the itemized billing is anyone's guess.

TriWest, knowing full well they didn't have the itemized billing, held this claim for one month, before denying it. A second copy of the itemized billing was sent to them on June 11, 2012, received by them on June 14, 2012. Today, almost a month later, TriWest has still not straightened out the mess they made of this claim.

Need number of minutes patient was under anesthesia. Oh, but wait, since the OHI paid 100% of allowable, that information wasn't really needed after all. And while TriWest deemed this information required, they still have not been able to explain how it is that they've paid one of the duplicate entries for this claim without that required information!

TriWest held this claim for one month before removing it. Why didn't they request this information when they received the claim? Again, they don't look for such things until the claim is processed. That way, if the claim doesn't meet edits, the claim can be denied/removed, and TriWest stands to make more money off the DoD contract!

Two or more primary insurance policies. In their infinite wisdom, TriWest decided that two policies, with the exact same policy number, from the exact same insurance carrier, for the exact same patient, must be two different policies! And even though this screw-up was the doing of TriWest, that 30 day clock started all over again!

Couldn't read the OHI EOB. After TriWest scanned the primary insurance EOB into their system, they couldn't read it. What happened to the originals? Well, uh, they just don't know! TriWest really thought we should supply them with another copy of the EOB. If they couldn't read the original EOB, after they scanned it into their system, what good would it do to send them yet another copy that they wouldn't be able to read after they scanned it into their system? The suggestion that maybe they needed to use higher quality scanners brought the reaction that the problem wasn't their scanners! Oh really, then why couldn't they read an EOB that was perfectly readable when it was mailed to them? To boot, what happened to the original EOBs they received on April 10, 2012; the EOBs that mysteriously have gone missing? The answer - they don't know!

Procedure had to be performed in a medical facility. And it was. And had TriWest done even a modicum of research, they would have seen the hospital claim that they denied for lack of a POA code, with the exact same date of service! Do you suppose there was a clue in there, somewhere? Did they check for a hospital bill before denying this claim? No. Why not? No answer.

EOBs without itemized billings. In their infinite wisdom, TriWest decided that taking claims apart was a grand idea. Then they couldn't figure out that the EOBs belonged to the itemized billings because the provider name on the EOB was not the same as the provider name on the itemized billing (these providers all work under the umbrella of the provider name on the itemized billing). Yet when they received the claim, the itemized billing was stapled to the requisite EOBs with a sticky note attached to the first EOB stating that subsequent attached EOBs were for the provider listed on the itemized billing!

Beyond that, TriWest has entered the same claim multiple times; sometimes lumping claims from different providers together; other times entering the claims singly. Then, being incompetent and inefficient, TriWest can't figure out what is what. And trying to explain to them what they have done is like talking to a brick wall; it goes right over their heads! To boot, they have denied claims entered multiple times under the premise that those claims were sent them multiple times by the beneficiary (us). That isn't true but certainly sounds better than admitting that they did it out of incompetence and inefficiency!

Other claims, they still haven't entered, two months after receiving them. Asked where those claims are, TriWest doesn't know! In the meantime, they've acknowledged receiving some of them.

Every time one of these claims has been denied/removed, it is given a new claim number, and the clock on the 30 day processing time starts anew. And every time one of these claims is denied/removed, for whatever reason, TriWest stands to gain monetarily at the expense of taxpayers footing the bill for TriCare through the DoD contract.

If you were paying for healthcare insurance, and they handled claims in this manner, would they be your healthcare provider for very long, or would you take your hard-earned money somewhere else?

To date, five complaints have been filed with the TriWest Healthcare Alliance Customer Relations in Phoenix, Arizona regards these claims. To date, not one of those complaints has been answered.

My Congresswoman, Cathy McMorris Rodgers, has been kept apprised of this continuing saga of incompetence and inefficiency. What has been her response? Her office sent an automated response assuring me that she is "committed to ensuring that those who have served our country receive the care, support and benefits that they were promised and that they deserve." Wow, and here I thought she didn't care!

And a complaint has now been filed with the Department of Defense. No indication has been received that anything is being done about that complaint either.

As of July 9, 2012, this saga continues. When will it end? Probably about the time TriWest has milked the DoD contract for every penny it can get by recycling these claims over and over again!

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Your tax dollars at work, people. For those who believe Obamacare is going to be beneficial, think again. For those who wonder how our country got in the economic position we now face, this is a microcosm look at how the government, at any level, operates. When you look at what has occurred here, with just these claims, when you look at the deliberate incompetence and inefficiency, then multiple the cost of that incompetence and inefficiency by the thousands of programs and departments run by the government, is it any wonder our country is broke?

There is a reason our Founding Fathers established a limited form of government, severely curtailing the authority of government - because, first and foremost, the priority of any government is to justify its existence. That can only be accomplished by convincing the people that the government needs more and more of the people's money in order to provide for them.

� 2012 Lynn M. Stuter - All Rights Reserved

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Activist and researcher, Stuter has spent the last fifteen years researching systems theory and systems philosophy with a particular emphasis on education as it pertains to achieving the sustainable global environment. She home schooled two daughters. She has worked with legislators, both state and federal, on issues pertaining to systems governance, the sustainable global environment and education reform. She networks nationwide with other researchers and a growing body of citizens concerned about the transformation of our nation from a Constitutional Republic to a participatory democracy. She has traveled the United States and lived overseas.

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And a complaint has now been filed with the Department of Defense. No indication has been received that anything is being done about that complaint either.