New info for Tricare Insurance users.

[dllfo]

If this is out of line, the moderator is welcome to delete it, but I just spent about and hour on the phone with Triwest and Apria Healthcare.

As I understand it, Tricare hired Triwest to administer the Western Region.
Whatever....there is a LOT of old information and plain old bad information
out here.

A supervisor for Triwest and a Customer Service Supervisor for Apria did a
conference call with me.

New---If you need equipment that costs under $2,000 you DO NOT need an
authorization from Tricare or Triwest. Just a prescription to the DME people.
Nothing else from you or your doctor. Other insurance companies may
offer this as well, just call and speak to a supervisor.

One caveat is that I am Tricare Standard (a PPO), if you are one of the other
two it may be different, but the supervisor for Triwest did not specify which
Tricare health plan a person had to be on. So if you need any DME under
$2000, and the doctor gives you a prescription. Fax it to your healthcare
provider for DME.

Another thing the Customer Service supervisor told me is that we can fax
the prescription to Apria and THEY will deal with Tricare/Triwest or whoever
is required. For me, this keeps the prescription for disappearing within that
huge company for days on end.

My problem has been the doctor's office sends the prescription to Triwest.
Good luck finding that one. After several days I get frustrated and raise
cane with them, they find it all-at-once. Hmmmm.

Based on this series of calls, I will ALWAYS request the doctor's office to
give me the prescription or fax it to Apria. NEVER to Tricare or Triwest.

I also asked them about the Auto Bipap software. Both said it was not
authorized...except in a few special circumstances, it seems that... if you can mail the card to your DME or Doctor, you are considered to have access to it by Tricare.

So I pursued the concept of going from Doctor to DME, without an OK from
the insurer. If I get a prescription for some new device...anything...
and I fax the prescription to Apria. The device is under $2,000, but Tricare
does NOT authorize it. What if Apria screws up and sells it to me? Am I
out the cost of this equipment because I bypassed the Triwest people?
Put another way, does the customer suffer for a glitch in the system? No
one really seemed to jump on that one, but the supervisor said they might
have to charge us a month's rent, then they would probably take it back.
So each individual may need to speak to their local DME to find out. My
DME right now is Apria in Sacramento, CA.

This piece of information will greatly simplify my life for the near future because I will send all faxes to the Apria supervisor. SHE can determine
what is appropriate and swears she will do it.

Any questions?

[pratzert]

No questions.... just a suggestion.

Whatever Apria tells you... get it in writing.

They consistantly LIED to me about the machine being supplied.

My Doc wrote s very specific prescription for a machine and Apria "Told" me that they deliver whatever machine the Doctor prescribes.

BUT... that was completely UNTRUE. They deliver whatever machine they feel like or have leftover in their warehouse, as long as it's the cheapest machine made.

Bottom line for me.... I ordered my machine through cpap.com and will pay for it out of my own pocket to be sure I get the machine my Doc says I need for my therapy.

EVIL DME's.

[Guest]

Interesting comments. As I said, the Apria in SACRAMENTO has went above
and beyond the call of duty for me.

They could have tap-danced, claimed they did not receive faxes, etc. but
instead, the lady running customer service took the initiative. She and others
made it happen. Since I can't drive due to meds, I needed their assistance.
They gave it.

Sorry if you had troubles with yours, but I can ask this customer service
supervisor to call you if you want. She seems to be willing to do whatever
it takes.

[Offerocker]

THANK YOU so much for taking the time to document your 'adventure' and lessening our learning curve. We have Standard. I haven't yet needed to use Tricare for DME, as I have private insurance, but Tricare should pick up the difference.
What happens if the amount is OVER $2,000, do you know?
And maybe they would pickup the excess if order is over 2000 and primary insurance pays first?
I'm on the East Coast (PA), which I believe they consider "North"?

Thank so much!

[Linda3032]

Yes, PA is considered the North Region and is handled by http://www.healthnetfederalservices.com, ph number 1-877-874-2273. If you have any questions, you can call them and they can either help you or refer you to your representative.

Our Tricare handbook says DME equipment has to be pre-approved, but 3 years ago I found out that under $2000 you need no prior authorization.

I've never dealt with a private insurance as primary and Tricare as secondary, regarding DME. But it stands to reason that you have to jump through the primary insurnace hoops first. And then file with Tricare.

It seems to me however, (and you should double check with Tricare), but if you purchase your equipment through cpap.com and submitte the bill to your primary private insurance, and if they deny your claim, then Tricare should pay for it at 75% leaving you a balance of 25% out of pocket.

That seems far easier to me than to try to rent a machine you don't like because of your private insurance, and having to jump through all their hoops.

With Tricare, file with your private, then refile with Tricare - just make sure you have an "itemized" invoice. ....

[dllfo]

Rats, I am the guest up above. I thought I was already signed in. Sorry about
that.

I would warn anyone dealing with Tricare to list the date, time and name of
every person you speak to. Your screen at their end has similar info. Actually
that is probably true of every insurance company.

I got a nebulizer from them last year. Regular large 110 volt AC kind. LONG
story short. I was told I could get a 2nd one because we were traveling out of
town. TWO Tricare "people"...the ones we call to ask questions of said I COULD get a 2nd one. TWO separate call centers. They were wrong. The money people said no. I bought an Omron NE-U22. It fits in my shirt pocket and I carry it everywhere.

Moral of the story is you cannot always trust what Tricare tells you. I would
recommend getting a supervisor if you have any doubts.

[OwlCreekObserver]

I learned another Tricare lesson this morning.

For the record, I have Tricare Prime (retired USAF) and Tricare is leasing my Remstar Pro c-flex. I don't know what my out-of-pocket cost is yet because I haven't been billed. My local Tricare rep said that there's really no way to know until the bill arrives. No real surprises there.

Anyway, I once worked for a DME provider (specialized equipment but not respiratory stuff). I remembered that many insurance providers will lease a DME item for some period of time (their determination) and then will just buy the item and provide it to the patient. What I learned today is that CPAP is not included in that category as far as Tricare is concerned. According to the rep, they'll lease it forever because of potential maintenance issues.

In light of that fact, and at the Tricare guy's suggestion, I asked my DME today what it would take for me to swap out my Remstar Pro for a Remstar Pro 2. At first they said that there wasn't much difference between the two, but then I explained to them that the older model only tracks compliance data, which isn't very helpful since I already know how much time I spend on the machine. I explained that I bought the card reader and software so that I that I could track my progress, be able to provide meaningful info to my doctor, yadda, yadda, yadda. He said "no problem" and though he didn't have any in stock at the moment, he has several on order and will call me as soon as they come in. So far, it's been a very good day.

One other thing: I'm almost positive that the $2000 limit applies only to purchases. My understanding is that all leased items must be approved by Tricare. If I'm wrong about that, I'm sure someone here will correct me.

OCO

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CPAPopedia Keywords Contained In This Post (Click For Definition): C-FLEX, CPAP, DME

[Linda3032]

And the rules for Tricare Standard and Prime are different.

Above $2000? You need to get pre-approval for the purchase.

[dllfo]

Hi Linda,
This whole tricare thing is a nightmare. You were told one thing about renting
versus buying. I was told the opposite.

I guess they outnumber us and by shear weight of numbers, shall prevail.
If they had to pass a competence test Tricare would be out of business.

If you and I had the regs on the internet, we might have a chance, but the last guy I asked about that said security prevented it.

[OwlCreekObserver]

This whole tricare thing is a nightmare. You were told one thing about renting
versus buying. I was told the opposite.

I guess they outnumber us and by shear weight of numbers, shall prevail.
If they had to pass a competence test Tricare would be out of business.

If you and I had the regs on the internet, we might have a chance, but the last guy I asked about that said security prevented it.

Having gone through 3 or 4 health insurance plans in the past few years, I'd have to say that they all have their own issues. In the three years that I've been enrolled in Tricare Prime, including a surgery and several referrals, tests and procedures, I really don't have anything negative to say about them at all. My local rep is extremely helpful, all claims have been handled quickly and accurately, and even getting in touch with their customer service folks at region hasn't been a problem. My primary care doctor is highly regarded by his peers and bends over backwards to give me whatever support I need.

Of course I haven't yet seen a bill for all this CPAP stuff, so my opinion may change. I've heard and read a lot of horror stories from all over the country, but personally I've been more than pleased with Tricare Prime.

[dllfo]

OCO--in the "big picture" you are correct.

I have to admit they have done pretty well...OVERALL.

But their formulary was designed by a Vegan Tibetan Monk from Arkansas with dyslexia, compounded with cranial-rectalitis.

I can spew out examples of their mistakes, but suffice to say that is one of my congressional complaints. Long story. Boring.

Here is a question for you. Several people tell you all you need to buy DME
is a prescription if it is under $2,000. You do that. Say...$1500. THAN another Tricare rep says it is $500. YOU are damaged if they do not reimburse you.

I am frustrated, as we all are at one time or another, but it will pass.

WE REALLY NEED THEIR REGS ON LINE SO WE CAN QUOTE IT TO THEM.

[OwlCreekObserver]

OCO--in the "big picture" you are correct.

I have to admit they have done pretty well...OVERALL.

But their formulary was designed by a Vegan Tibetan Monk from Arkansas with dyslexia, compounded with cranial-rectalitis.

I can spew out examples of their mistakes, but suffice to say that is one of my congressional complaints. Long story. Boring.

Here is a question for you. Several people tell you all you need to buy DME
is a prescription if it is under $2,000. You do that. Say...$1500. THAN another Tricare rep says it is $500. YOU are damaged if they do not reimburse you.

I am frustrated, as we all are at one time or another, but it will pass.

WE REALLY NEED THEIR REGS ON LINE SO WE CAN QUOTE IT TO THEM.

Don't hold back, just tell us what you think.

Actually Linda3032 might have some thoughts on your Arkansas comment.

Seriously, I can't disagree with anything you've said. And if I'd gotten stung by bad info like that, I'd probably be even less delicate about it. I'm with you 100% about better on-line info also. Their search engine is practically useless.

But right now my biggest concern is trying to SOMEHOW get used to strapping on my headgear every night, turning on the pump, and trying to sleep that way. I thought it was supposed to help me sleep better!

OCO

[dllfo]

Linda? Uh...Arkansas...uh....did I mention I lived in Wesley, Ark. for awhile?

Sorry Linda, didn't mean to offend my cousins in Ark. saying they can read and all. I won't do it again. javascript:emoticon(':lol:')
Laughing

Any large organization has its problems, but they really need a way to rectify them and Tricare is lagging behind. BUT before I blast Tricare, we have to remember who is the real culprit.....Congress.

OCO...did you notice how cute Linda looks with her hair cut like that?? My wife is laughing at me ....trying to cover my tracks and as she said.....when you have dug yourself into a hole, the best thing to do is quit diggin' ------

[Linda3032]

. Grrrrrrrrrrrrrrrrr, and you'd better quit digging.
Okay, all is forgiven.

I agree that Tricare can be "trying", especially so with the 3 different levels of care (guess that is why they call it Tri-CAre). Big Duh.

Here is a very good example that happened to me this year.

I called my rep (don't remember when at this point), and asked if I could get another machine or if there was a time limit. She said no problem - as needed. So, I bought my new machine in March. I followed the same procedure I did 3 years ago. As a Standard dependent, I bought the machine online, and submitted my paid invoice so I could get reimbursed. Well ........................

(Now get this), Tricare standard changed their policy as of January 1st, 2006. As of that date, I had to get pre-approval for DME equipment over $500.

(Now this is even funnier), On April 1st, 2006 they reversed the newly changed policy and went back to the old one. Which is "pre-approval if over $2000.

But, I fell into the 3 months of the new policy period, so they are giving me grief because I didn't get pre-approval. Worst case scenario, I'll be out $725 or so, but it's the principle of the whole thing. And you can't argue with the US Government. I am appealing their policy, because I shouldn't be penalized because of their 3 month rule change. I'll let you know if I win or not.

I do feel that when they change their rules, that new booklets should be sent out to us. Otherwise, how are we to know?

(sorry, long story)

[OwlCreekObserver]

But, I fell into the 3 months of the new policy period, so they are giving me grief because I didn't get pre-approval.

Which just proves my long held belief that the only thing the feds are capable of doing well is defense. And even that's a little shaky sometimes.

I gotta believe that they'll eventually do the right thing regarding your situation. A note to your congresscritter probably wouldn't hurt.

OCO