March 25, 2013
On April 1, 2013, UnitedHealth Military & Veterans Services (UMVS) will begin providing managed care services to 2.9 million TRICARE beneficiaries in the 21 western states, including California. On that date, UVMS will be taking over the contract previously held by TriWest.
United began soliciting physician participation in its new network in September 2012, but many physicians report they did not receive the contracts until January 2013.
Physicians should be aware that the terms of the various contracts sent to physicians may vary and are encouraged to closely review the proposed contract terms. For example, some contracts may lock physicians into the UMVS contract with no ability to terminate from one to five years, depending on the termination clause in the specific contract.
Other areas of the contracts that warrant further review and consideration include:The “Network Providers” section of some contracts states that if 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. The California Medical Association (CMA) expressed concern with this provision and UMVS later removed this language. For those who may have signed the older contracts, UMVS is in the process of issuing a contract amendment to remove that language. The recoupment section of the UMVS contract states they may seek an overpayment “at any time.” CMA was concerned that this language may not be consistent with federal regulations, however UMVS has clarified that while the regulations do limit the contractors’ ability to offset or clip money due from future payments to 10 years, they can pursue overpayments beyond that timeframe through other methods.The “Prior Authorization” section states that 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. Section 2, sub-section 2.1 of the Payment Appendix states physicians will be paid the lesser of either 80 percent of their billed charges or the contracted percentage of the Tricare Maximum Allowable Charge (TMAC) rate. However, CMA has learned that UMVS has modified the contract to now pay at the lesser of either 100 percent of the physician’s billed charge or the contracted percentage of TMAC rate. UMVS will be issuing contract amendments to those who signed the older contracts that contained the 80 percent figure.
While this last item is a positive change for physicians, it is also a reminder about the importance of reviewing the charge master at least annually to ensure you are not leaving money on the table. For more information on developing a defensible fee schedule, see chapter 8 of CMA’s Best Practices, a guide for improving the efficiency and quality of your practice," available free in CMA's online store.
In addition to the issues noted above, CMA has a number of other operational and contract questions regarding the transition. CMA will be meeting with UMVS representatives this week and will provide additional information in the very near future.
United Healthcare is hosting a series of webinars in the coming weeks. The webinars will cover TRICARE eligibility, programs, clinical programs, provider types and access, referrals and authorizations, claims and reimbursement and provider resources.
Physicians who have questions or are interested in participating in the UMVS TRICARE network but have not received a contract can contact UMVS at (877) 988-9378.
Questions: CMA’s reimbursement helpline, (888) 401-5911 or email@example.com.