February 08, 2013
Area(s) of Interest: Payor Issues and Reimbursement Practice Management
As previously reported, UnitedHealth Military & Veterans Services (UMVS) began soliciting physician participation in its new provider network, which will serve TRICARE beneficiaries beginning April 1, 2013. While some physicians may have received the contract notices as early as September 2012, others report they did not receive the contracts until January 2013.
The California Medical Association (CMA) has learned UMVS sent three different notices to physicians. One notice went to physicians whose United contracts do not permit unilateral amendments, inviting them to participate in the TRICARE product and asking them to sign and return the enclosed amendment. Another notice went to physicians whose United contracts do allow unilateral amendments, advising they would be automatically opted into the UMVS TRICARE product unless they opted out in writing within 30 days of receipt of the letter. A third notice went to physicians who are not currently contracted with United, but are contracted through TriWest for the TRICARE product, asking them to sign a UMVS contract.
Physicians should be aware that the terms of the various contracts sent to physicians may vary and should be reviewed closely. For example, physicians may be locked into the UMVS contract with no ability to terminate from one to five years, depending on the termination clause in their specific contract.
Additionally, the Network Providers section of some contracts states that in the event a provider refers a beneficiary to an out-of-network provider without a referral or prior authorization, the referring physician will be responsible for payment of the claims incurred. CMA expressed concern with this provision and as a result, UMVS later removed this language. However, CMA is seeking clarity from UMVS on how they are handling those contracts that went into effect before the language change.
CMA is also seeking clarification on language in the Recoupments section, which states UMVS may seek an overpayment “at any time.” CMA is concerned that this language may not be consistent with federal regulations, which limits TRICARE contractor’s ability to pursue overpayments to 10 years, except in cases of fraud.
Physicians should also note that per the Prior Authorization section, in emergent situations physicians are required to notify UMVS within 24 hours of providing services that would typically require a prior authorization. UMVS then has the “final binding authority” to decide whether a medical emergency existed and, if not, providers will not be reimbursed and cannot bill the patient.
CMA continues to work with UMVS to obtain clarity on these provisions and will publish updates as they are available. Physicians with questions about the TRICARE network and contract can call UMVS at (800) 718-7572.
Contact: CMA reimbursement help line, (888) 401-5911 or firstname.lastname@example.org.