Vet News: Itemized Billing Streamlines TRICARE Outpatient Care Payments

The Department of Defense (DoD) Military Health System (MHS) converted to "itemized billing" a few months ago to streamline the process for billing uniformed services beneficiaries, third-party payers and persons not eligible for TRICARE for outpatient care received at military treatment facilities (MTFs). The new billing approach does not change access to care for TRICARE beneficiaries. It does, however, change the way those who have other health insurance (OHI) are billed for outpatient care received at a MTF.

Previously, outpatient bills were calculated using an all- inclusive or "single rate" per visit. The single rate covered not only the provider’s fees but also fees for laboratory, radiology and pharmacy services received during an outpatient visit. Under itemized billing, each outpatient service or treatment provided is clearly annotated on the claim form (billing statement for non-DoD patients,) along with all associated charges. In addition to the itemization of charges for services received during an outpatient visit, MTFs are now also able to bill-third party payers for prescriptions filled from orders received from physicians within the MTF.

The move to itemized billing came as a result of the 1996 Health Insurance Portability and Accountability Act (HIPAA) that required the MHS to conform to industry billings standards; the Fiscal Year 2000 National Defense Authorization Act (NDAA) that required DoD apply reasonable charges when billing third-party payers and non-DoD beneficiaries; and from concerns expressed by beneficiaries and third-party payers that the all-inclusive single rate was too ambiguous for use in processing claims.

Overall, the transition to itemized billing is a win-win situation. Beneficiaries who have OHI and receive care at a MTF can now receive an explanation of benefits (EOBs) and bill that clearly identify the health care services received and their associated cost. DoD benefits from the collections received, which can be put toward resources to support medical services and other patient-related initiatives at MTFs. Third-party payers also receive a benefit. Claims submitted by DoD are now similar to claims submitted by civilian providers, which creates assurance for payers third- party payments made to DoD mirror established industry practices. While DoD’s initial efforts have focused exclusively on outpatient care, plans are underway to convert billing practices for inpatient care to itemized billing later this year.

Beneficiaries who have questions or concerns about an itemized bill or EOB should contact their regional managed care support contract claims processor or TRICARE service center representative. A list of local and regional toll-free telephone numbers is available on the TRICARE Web site at www.tricare.osd.mil/regionalinfo/

Third-party payers with questions are encouraged to contact the billing office of the MTF submitting the bill. General DoD medical billing information is also available by submitting questions by e-mail to the DoD Uniform Business Office at mailto:[email protected] or by calling (866) STI-4UBO (866) 784-4826.

SOURCE: TRICARE News Release, http://www.tricare.osd.mil