Payments > Insurance Payments

UNLAWFUL CHARGING???

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aremy44:
Is a physician who is not contracted with Tricare or any other insurance except Medicare required to reimburse a Tricare patient who came to  him and self paid for services? the patient was aware of the fees upfront when he came in for an appointment and we billed Tricare as a courtesty as we do for all our patients. But now after getting reimbursed he is stating that according to Tricare he was only responsible for 15% above the allowable and that the physician has to reimburse the rest. Has anyone heard of this? Is it true?

RichardP:
See the heading Non-Participating Providers ... at the bottom of this link.

http://www.tricare.mil/FindDoctor/NonNetwork.aspx

Specifically:

The provider has the legal right to charge up to 15% of the TRICARE allowable charge. Any charges above the allowable charge are your responsibility and will not be reimbursed.

Tricare may pay up to 115% of their allowable charge.  Patient is responsible for any monies due above that 115%.

If this wasn't explained to the patient by your office, you can still insist that the patient pay.  But, if you do that, and patient bad-mouths your business, it may not be worth it in the long run.

aremy44:
Thank you for that response, however that leads me to another question. Since the fees my physician charges are way above the 15% increase over the allowable, is my physician doing something illegal? I was under the impression that a physician would have to apply to be a certified or authorized Tricare provider. We have no such application on file here, and what is worse I was told that simply because the physician filed a claim on behalf of a Tricare patient he is now considered authorized and is bound by their rules. This is essentially like roping a physician into accepting their insurance benefits. How can this be? For other commercial insurances they pay what they allow and basically the patient has the responsibility of paying whatever their insurance does not cover. In a private contract between the patient and physician how does the physician end up having to reimburse the patient after insurance has already reimbursed their portion to the patient?

RichardP:
I was under the impression that a physician would have to apply to be a certified or authorized Tricare provider.

Your statement is correct:  ... to be a certified or authorized Tricare provider.

But not all providers are authorized to be part of the Tricare network.

In the link I provided, Tricare makes it clear that the patient is not required to see an authorized Tricare provider.  However, if they do see a doctor that is NOT an authorized Tricare provider, the patient is responsible for any charges above 115% of Tricare's allowable amount.

aremy44:
You have made me a very happy camper today. I thank you and so does my physician. Thanks a bunch. ;D

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