ABC May2023 BW  92

By Joseph Mitchell

As the owner and founder of ABC, it seemed pertinent to speak about the difficulties with one particular insurance company. TriCare is a healthcare program of the U.S. military that provides health benefits to military families. Within the ABA industry, they have gained a reputation of being challenging to work with. Dealing with them regularly causes long delays in service and has led a number of ABA companies to not accept TriCare in any capacity. Consider this – TriCare has managed to make dealing with other insurance companies seem simple; that is quite a feat!

I have no desire to make people wait for weeks or longer, particularly when they have no other help. I feel confident in saying other ABA companies do not want to turn people away because of their insurance. Yet, extensive delays in service because of Tricare are commonplace. They have my organization spending more time on credentialing, authorizations, and re-authorizations than helping the clients. 

I began my private practice in 2015 and knew the importance of exploring all options for credentialing. Credentialing is a fancy word insurance companies use to see if you are ‘qualified’ to become ‘in-network’ with them. When you are a small business owner in an emerging field, you accept these hurdles as part of the natural course of things. You jump through hoops due to naivete or wanting to be accepted the way that other more established fields are accepted. My small group of clinicians were lucky enough to have made it through the TriCare credentialing process.  

Once credentialing is completed, then we can begin to work with clients. Well, almost. Before that, we need to get authorizations for each individual client. 

The authorization process, put simply, is a nightmare. The scrutiny with TriCare is bar none the most difficult I have ever dealt with in my 23 years of experience. The focus is on details like employee’s individual identification numbers (a requirement no other insurance company has). This, on top of a litany of miscommunications from and within Tricare, unnecessarily complicates and lengthens the process. Different departments tell you conflicting information. They accept some documents but not others with no rhyme, reason, or pattern. ‘Sorry, we don’t want that background check, you’ll have to do another one,’ or, ‘we changed our policy on that, sorry you were not informed… start over.’ 

Then, once authorized (momentary sigh of relief) you then find out that they only authorized you for an assessment, and a whole new authorization process begins for treatment. Wait! We have to do the same things all over again? My agency provided six weeks of free service to a TriCare family because it took that long to satisfy TriCare’s demands. Guess what? Children with immediate treatment needs do not have six weeks to wait around while the wheels of bureaucracy turn. My small company swallowed that loss. 

This is where the long delays in service occur. Many companies will not provide services for those six or more weeks rather than have to suffer the loss. Honestly, I will likely handle it differently in the future. I do not want to make people in need wait, but a small business can only take so many losses. During this authorization process, we seriously reconsidered taking on more TriCare clients due to the tremendous amount of time and effort that was required of my clinical and billing staff. 

Once we finally get an authorization, TriCare requests constant and repeated audits. As if it was not challenging enough to work in this field on a daily basis, we now have to deal with constant audits. In general, oversight is fully fair and necessary. However, it should be focused on ensuring that providers offer the best possible service. 

We quickly found out that these audits were purely about how much money could they claw back. They offer seemingly arbitrary evaluations to claw back money or not pay providers at all. One of our therapists entered 12:15 pm instead of 12:00 pm as a start time for a session. TriCare refuted this date of service because records do not match. They ask for money back from the full session containing these type of minor time discrepancies. Another therapist printed her name instead of signing her therapy note. TriCare wants their money back again! I could share many more examples. 

It is no wonder that some companies outright do not accept TriCare. No one wants to deal with red tape. No one likes to jump through hoops. No one wants to be told that the rules were clearly laid out in a 250 page document. While a certain amount of oversight is most certainly needed, it should be focused on what is important. It should be concern for the quality of service, not whether someone printed or signed their name. 

In the fall of 2023, I wrote to TriCare to express these concerns. We have yet to receive any response. 

To this point, I have expressed the difficulties from a provider standpoint. I have also received feedback from TriCare families with the same frustrations. One family who was desperately seeking services had called every ABA company within a 20 mile radius. Out of the previous eight companies they had reached out to, my company was the only one that even accepted TriCare clients. 

Once again, TriCare further delayed the client’s start date due to miscommunication between their departments. This particular family was so thankful and appreciative that we were willing to go the distance with them to make this happen. It is a sad state of affairs that this is the experience of military families who are already making tremendous sacrifices on behalf of our country. 

Some might find sharing my experience to be provocative or combative. I do not wish to be that way. I simply want to be heard. On behalf of other ABA companies whom I know have gone through the same experiences, I just want it to be known what we experience on the provider end. Military families deserve the best treatment and utmost care given the hardships they experience. We all should be unsettled about the difficulties they face receiving the services they deserve – whether it be ABA therapy, mental health services, or any other service they may seek. The system cannot be improved until we recognize the problem. ABC continues to accept families with TriCare, but we simply want to define the problem so we can find a solution to continue serving military families for the foreseeable future. We seek a remedy, not a quarrel. 

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