Does anyone out there deal with Tricare??

Just have some questions about Tricare??  If you havethis insurance could you please post?  I have some questions.  Thnk you.

I have Tricare, and am also an licensed insurance agent, I know the system in and out, upside down and backwards. Feel free to contact me.

I too am trying to use Tricare as a secondary insurance.  I am in the appeal process with Fed BCBS (it is looking promising).  If they approve will Tricare follow?  Any thoughts on how to get them to step in as the secondary?

Thanks for your help!!

Beth

Tricare does NOT cover VSG outside of military hospitals as a primary or secondary insurance. They won't cover it until Medicare fully endorses and covers it.

I've fought with Tricare for 2 years, have helped friends appeal, one took it all the way to a Congressional complaint level and it was still denied. She ended up switching to Tricare Prime and went to a military hospital and had her VSG performed without issue.

It's just not going to happen until Medicare picks it up fully. Just like when they denied the band surgeries. It's a non-covered procedure, and I've witnessed friends go through the entire process with a pre-authorized letter with a civilian, and then when everything was submitted to Tricare for final approval they spent 6 months jumping hoops, and BAM a denial was handed down.

I spoke with a claims manager in the Tri-West, Tricare South (Humana manages our Tricare), and Tri-North, in February and they all made the same statement " VSG will not be covered until the review of procedures is started in the summer of 2011, with final determination for the budget for fiscal year 1 October 2011". It's the same line we heard in 2009, and last year. So, I'm not holding my breath for coverage. I'm not trying to be a Debbie Downer, but with my experience, and several friends that have fought with Tricare for 2 years on this one, I have never seen one dependent get VSG covered outside of an MTF with Tricare Standard or Tricare Remote or Tricare for Life. The only exception for the Tricare for Life friend I have is she went through the VA and had it covered however they process things. Not once have I read, spoken to, or seen on VSG covered with a civilian, and I stay on top of it monthly.


Since it's a non-covered procedure, I"m not sure you could get  them to cover any of the hospital charges, anesthesia charges, op room fees, etc etc. But, it's my understanding that if it's a non-covered procedure, nothing will be covered including any follow up. I was warned when I had my VSG that until VSG is not covered by Tricare that if I sought treatments/labs/endoscopes etc etc outside of an MTF, then I could be billed for the services even though they covered the surgery.

One thing that we have to remember is that surgeries performed at MTF are not really paid out by Tricare. Those surgeons get paid on the 1st and 15th regardless of what surgery they perform, regardless of how many surgeries they perform, Tricare just sets the guidelines for approval, but it isn't Tricare paying the surgeons, it's DFAS (military) or by contract with the DOD,that surgeon makes the same amount every pay period regardless. Tricare doesn't have negotiated fees contracted with military surgeons, they don't have contracted rates with military hospitals so it's a little different when we have procedures performed at a military facility vs. with a civilian or private labs/clinic.

I hope that makes sense. It's a very frustrating situation, and I've written my representatives, gone through patient advocacy to get it covered, sent emails, letters, and everything I can do to get it covered. Unfortunately, it's a government ran health system and they aren't in any hurry to approve more services.

I have tricare as secondary and found out they would not pay for my VSG, so i have to pay the 15% left over....not sure about the hospital but this was for the Doctor part.

 I have Tricare. If you are near a military treatment facility it is much easier to get the VSG there. Otherwise it can be frusterating to get it approved.

Tricare does NOT cover VSG outside of military hospitals as a primary or secondary insurance. They won't cover it until Medicare fully endorses and covers it.

I've fought with Tricare for 2 years, have helped friends appeal, one took it all the way to a Congressional complaint level and it was still denied. She ended up switching to Tricare Prime and went to a military hospital and had her VSG performed without issue.

It's just not going to happen until Medicare picks it up fully. Just like when they denied the lapband surgeries. It's a non-covered procedure, and I've witnessed friends go through the entire process with a pre-authorized letter with a civilian surgeon, and then when everything was submitted to Tricare for final approval they spent 6 months jumping hoops, and BAM a denial was handed down, through appeals, and peer to peer reviews, the procedure was always denied coverage.

I spoke with a claims manager in the Tri-West, Tricare South (Humana manages our Tricare), and Tri-North, in February and they all made the same statement " VSG will not be covered until the review of procedures is started in the summer of 2011, with final determination for the budget for fiscal year 1 October 2011". It's the same line we heard in 2009, and last year. So, I'm not holding my breath for coverage. I'm not trying to be a Debbie Downer, but with my experience, and several friends that have fought with Tricare for 2 years on this one, I have never seen one dependent get VSG covered outside of an MTF with Tricare Standard or Tricare Remote or Tricare for Life. The only exception for the Tricare for Life friend I have is she went through the VA and had it covered however they process things. Not once have I read, spoken to, or seen on VSG covered with a civilian, and I stay on top of it monthly.

Thanks so much for the great information ~ while disappointing, it is good to know on the front end.  I'm keeping my fingers crossed for Federal BCBS to come through this week.  They only have 4 more days to respond!!!

Thanks again!

Beth

I have Tricare and started out on the "outside" but was denied.   As it turned out, I am very happy!
I do not feel I could have gotten better care ANYWHERE that what I got with Dr. Pfluke and his staff at Wilford Hall in San Antonio!  
We live about 200 miles from Wilford Hall but that was not an issue for us.  
Good luck on your journey!