Troubled transition: Tricare changes endanger autism therapy services for military families
By DIANNA CAHN | STARS AND STRIPES Published: February 16, 2018
WASHINGTON — The letters, as if coordinated, began going out the third week in January.
First Anchorage, Alaska, then Jacksonville, Fla. Soon military families in Texas and Alabama hubs received notices too.
Despite months of preparation, the 2018 overhaul of the military health insurance company Tricare was not going smoothly, the letters from service providers explained. Tricare’s new management companies were not reimbursing providers and not responding adequately to phone calls, emails or online submissions.
So therapy clinics like Bloom Behavioral Solutions in Jacksonville, Integrated Solutions in San Antonio, Texas, and A Perfect Fit, AK near Anchorage, which offer behavioral therapies for children with autism and other challenges, were finding themselves without recourse -- unable to cover the costs of the expensive therapies for children of military families. Services would have to be slashed, each letter said.
“Despite all our efforts to maintain services without Tricare reimbursement, we are at a point at which we can no longer continue to provide ongoing services for Tricare beneficiaries for which we are not paid,” Bloom Behavioral wrote on Jan. 19. “Beginning on Wed. Jan. 24, we will have to put all services for Tricare beneficiaries on hold.”
For parents, the news was stunning. These therapies were not simply beneficial; they give their children skills to cope with everyday life. Losing them could be devastating for a child’s progress.
“I walked into the clinic room and there were parents in tears,” said Mary Nelson, a Coast Guard wife whose 7-year-old receives hours of behavioral therapy each week at Bloom. “Everything changed so abruptly. This is life-altering for these kids.”
In Alaska, Jeri Romesha received a similar letter Jan. 17 from A Perfect Fit, AK, the center where her 6-year-old daughter and her 3-year-old son receive a total of 30 hours of therapy a week.
Romesha, whose husband is a senior master sergeant at Joint Base Elmendorf-Richardson in Anchorage, started pounding the phones. First she called HealthNet Federal Services, which took over the Tricare West contract Jan. 1. But after hours on hold and no way to leave a message without giving her entire Social Security number, Romesha took a different tack.
She reached out to HealthNet contacts she had through her work as a Transition Assistance Program manager on base. By chance, one of them was a regional director.
“Services for my kids are being canceled and stopped because of these problems,” Romesha told him. “This is not the way to do business.”
The director stepped in, and the providers got paid, Romesha said. “Frankly, we got lucky. If I hadn’t reached out to the connections I had, we wouldn’t have services now.”
Across the country, parents and providers say they are facing overwhelming obstacles to sustaining services under Tricare following the Jan. 1 reorganization that included merging Tricare East and Tricare South and changing out contracts for Tricare East and West.
Servicemembers and family members have reported difficulties connecting to online systems and hourslong waits to speak to customer service. Parents and providers said they learned more from each other in online forums than from attempts to reach their insurance representatives.
Meanwhile, providers say reimbursements are patchy; they are slow to be approved; many providers are being reimbursed at rates of less qualified professionals; and the management companies – Humana Military in Tricare East and HealthNet in Tricare West – are slow to correct errors or address problems.
The Defense Health Agency says it is aware of the problems, particularly in Tricare East, and it has established a joint DHA/Humana Autism Task Force to resolve issues. It also says many of the problems have been corrected or are being resolved. But providers say that while claims that do go through without error are being processed more quickly, many of the issues still persist – including frequent errors in processing, payment rates and full reimbursements.
Bloom is among several companies that managed to continue some services by taking out expensive urgent high-interest loans. But that’s not sustainable for very long.
“It’s a mess,” said Amila Smith, a partner at a Compass Behavioral in Atlanta, who is concerned that if things don’t get better, the company will have to opt out of Tricare. Her company took out a loan as well.
“We don’t want to interrupt services,” she said. “A lot of our clients, we have had for several years and we’ve made such good strides for them. But we can’t keep borrowing money to run the business.”
Anything but smooth
In rolling out Tricare’s largest overhaul in two decades, the military consolidated its massive health care program from three regions into two, keeping Tricare West intact and merging north and south into a single Tricare East Region. New management contractors were brought in for both regions.
Months before the rollout, providers said they sent their rosters and credentials to the new companies to ensure a smooth transition.
But the Jan. 1 transition was anything but smooth.
Some providers did not get their credentials. Referrals weren’t going through, and soon, problems emerged with claims processing.
“We were prepared for this merger,” said Bloom Behavioral Solutions co-founder and CEO Genevieve Covington. “We had everything signed well before (the transition). My business partner and I had been saving for a two- to three-week delay. But nobody could have prepared for this situation.”
Providers complain that the website would not allow verification of basic information like names of providers, authorization to service a client or corrections to erroneously processed claims.
Covington said her center went from having six board certified behavioral analysis therapists (BCBAs) to four, when Humana failed to credential two of them. That automatically cut back on their ability to serve clients.
Humana was also failing to pay out properly and mislabeling the coverage or level of certifications, several providers said. Trying to rectify those errors amounted to dozens of hours a week on the phone.
In one instance, Covington said Humana processed one of two siblings receiving dozens of hours of applied behavioral analysis (ABA) a week as out of network and the other as in network. The active-duty parents were charged hundreds of dollars a day for services that are supposed to be covered. Despite a loan that Covington and her business partner took out ahead of the changeover, Bloom found itself struggling and warned parents they might have to ultimately cut services to all Tricare patients.
Unsure which services would be reimbursed, they put salaried BCBAs on hourly rates, cut back on hours and the owners stopped paying themselves salaries. They have, so far, managed to stay afloat, but know they won’t be able to sustain that forever, Covington said.
In Georgia, Smith said her company was told in January that their paperwork was not valid because Humana had not yet begun operations. Their provider representative told them she’d look into it, Smith said, but did not get back to them for weeks.
With more than 50 Tricare patients and similar problems with processing and payment errors, lack of credentialing and an improper fee schedule, Smith’s company Compass was struggling.
Meanwhile, parents said they could not get answers on co-pay hikes and spent hours trying to reach customer service
Similar things were happening with HealthNet, although the Defense Health Agency says those problems are less severe.
At A Perfect Fit, BCBA Kelly Forestal cut back her work hours so the company could pay its more junior registered behavioral technicians and keep services running.
“Thank goodness the technicians continued to work,” Forestal said. “If we had gotten to the point where we had to terminate their services too, that could have been disastrous.”
Forestal said HealthNet rectified many of the issues after one of its local officers stepped in, but it is still paying lower rates for ABA professionals, which she worries could force companies like hers out of Tricare.
Right now, she said, she’s less worried about the money than about ensuring the kids get the therapy they need.
“For a lot of kids … therapy is part of their routine,” she said. “When we take their routine away, it’s really confusing for them. So it not only takes away all those learning opportunities they otherwise would have gotten, that change in routine can really destabilize their learning and cause a lot of problem behaviors.”
When she realized that problems with Tricare were happening around the country, Mandy Farmer fumed. How was it that she was getting calls weeks into the rollout of the Tricare changes saying that the new management company needed more information before it could approve her son’s provider? How could Tricare and the Defense Health Agency spend months preparing for the 2018 transition and still get it so wrong?
This wasn’t the first time Farmer has had Tricare problems, but she said she had never seen it this bad. The Air Force wife and advocate for parents of autistic kids penned a scathing post on her blog “From Motherhood.”
“I’m either going to cry or punch someone,” she wrote. “Military families all over the country are receiving notice that services for their autistic children will cease because Tricare’s new contractors are not paying providers. Tricare knows. The Defense Health Agency knows. Everybody knows. Nobody cares.”
“Is it just me, or is this a smart way for them to save a lot of money?” asked Farmer, whose husband is an Air Force colonel at Ellsworth Air Force Base near Rapid City, S.D.
Farmer has a child struggling with autism who has benefited greatly from behavioral therapies that the family could not afford without insurance.
Her son Evan, 7, was getting 10 hours of behavioral therapy a week for severe aggression. He had three therapists who worked with him on skills for coping and sharing and on being around his siblings without acting out. The biggest thing were community outings with the therapist, who would help him learn to cope in strange or public places.
The treatment is very methodical – training an autistic child through consequences and patterns, like taking toys away if they behave badly and giving them back one at a time as they behave well.
Before therapy, Evan had dozens of incidents a day, Farmer said. Now he has one or two a week.
But when two of his three therapists had to stop working with him last month because of the Tricare problems, he lost six of his 12 hours of therapy, and his schedule changed as his provider struggled to keep services going.
For an autistic child who thrives on structure and predictable planning, the sudden changes were overwhelming.
It is “yanking the rug out from under them,” said Farmer. “It’s devastating to families.”
‘A number of challenges’
DHA, in a statement Thursday, stated that it was aware of the problems in credentialing providers and paying out claims – particularly for services to special needs patients receiving ABA for autism spectrum disorders. It committed to resolving the issue and closely overseeing Humana’s performance.
“Resolving the issues families are facing is our highest priority,” the statement said.
It also outlined improvements, including adding a special customer service number for ABA providers and additional training for customer service representatives. It has held three provider webinars and says ABA provider credentialing now takes an average of 17 days and work is being done to reduce that to seven.
“All errors inappropriately denying ABA provider claims were corrected as of Jan. 25,” the statement said. “All claims are now processing correctly and all prior claims that were processed incorrectly have been reprocessed with no action needed by the provider. Claims from ABA providers are now processing and being paid in an average of seven to 10 days.”
But providers like Covington and Smith say that while claims processing time has improved, problems continue. Providers say they still must spend hours on the phone to get errors corrected, and many are still not getting fixed. They are still owed reimbursements, and credential problems remain.
Covington said she lost another board certified therapist this week because of the instability.
Smith said that after two meetings with a Humana supervisor to try to get credentials for one of her BCBAs, she wrote to DHA this week to say she had to turn away one of her patients because she couldn’t get the child’s therapist credentialed. DHA responded with an offer to assign another provider for the child rather than resolving the underlying Tricare issue.
With a 70 percent caseload through Tricare, Smith worried that if issues continued, Tricare would put her out of business.
For parents, the confusion remains.
Many are receiving only partial services and they worry about the short- and long-term consequences for their children.
“We need to get the word out there,” Mary Nelson said. “These families are suffering.”