Payments > Insurance Payments
Tricare East Offset/Recoup
mandaree23:
Can someone please help me and tell me if you've seen this or have a suggestion on how to handle this?!
The first week of September I received a letter from Tricare stating that they are recouping several claims. The explanation states "An overpayment has been made on the below referenced claims. The original payment was based upon an error in the system logic: therefore, a recoupment is being initiated for the overpayment amount." I called Tricare and was told that there was a recent DME POS update that resulted in overpayments. He could explain what that meant and could offer nothing beyond that. I told him that I saw a notice on the Tricare website from 6/26/19 stating that there was an issue with DME capped rental items being reimbursed incorrectly. I asked if that could be the issue and he did not know and said to send in a letter and ask for an explanation and mention that we do not offer DME rentals. I sent the letter to the address he indicated and haven't received a response and that letter was mailed on 9/4/19. Today I received an EOB showing that they are beginning to offset my payments. There is a remark code that states " Payment for drugs infused through Durable Medical Equipment (DME) are priced at ASP plus 6%, in accordance with Section 5004 of the 21st Centry Cures Act and TRICARE's requirement at 10 USC Section 1079, to rimburse like Medicare." So I research and see that this rule they are referring to applies to drugs infused through DME. I assume this means infusions, chemo, insulin, etc. We only offer orthotics and prosthetics. I called Tricare again today, and we all know how that goes. She cannot tell me anything other than the same information on their original letter. I explained everything to her that I've stated here and she told me I just need to wait for all the offsets to be completed and then I can request reconsideration. *Also, I did make the spelling errors, that's actually how it is on my EOB.
Michele:
???
Wow.
What are the services that you billed for that are being recouped?
I haven't heard of anyone else having this issue yet. Just curious, is it TRICARE East? West? or South?
mandaree23:
Yes, it's very frustrating because I cannot find information on this anywhere and no one at Tricare knows. Our Provider Rep has not responded to me, and never does so I don't expect a response.
They are recouping our AFO's, SMO,'s etc...all primary codes on claims in question are L1960, L1970 or L1907. I have looked back at some of the claims online and they have changed the allowables on the claims but have not provided me with updated EOB's. I pulled one claim and looked at the difference between previous allowable when claim was paid and what they show now. Every line item has been adjusted by 19.05%
We are in Texas and claims are handled by Tricare East.
Michele:
I found the following article: https://media.defense.gov/2019/Aug/22/2002173972/-1/-1/1/DODIG-2019-112.PDF
It sounds like they were paying higher allowable amounts than they were supposed to be. I'm not sure if the specific DME you provided are included. Can you try to contact your provider rep's supervisor? We had an issue with a Beacon provider rep never returning phone calls. We contacted provider service and complained. She called back rather quickly after that. With TRICARE being a government agency those things don't always work, but it's worth a try.
mandaree23:
I had come across that article but it does not indicate all HCPCS and/or CPT this applies to. I did receive a response on one patient that I sent a letter in on and all it says is "This recoup is due to the DME place of service rates. You can view the rates at health.mil if you have any concerns."
You're right, its the government and I can't through to anyone else. I am not done trying though. If I receive any helpful information I will certainly share with you. Thank you SO much for all your help and research.
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