Staying the Course for Military Families with TriWest

In February, I shared our work removing barriers for military families who receive TRICARE benefits through Humana Military. We’ve been working just as hard for families whose benefits are administered by TriWest. In fact, climbing that hill has been even more challenging.

TriWest had all the same issues as Humana Military:

• For providers that had previously worked with claims manager PGBA, the database didn’t update their records.
• That meant PGBA had incorrect info for hundreds of applied behavior analysis (ABA) organizations and individual providers, preventing claims from being paid.
• Providers experienced barriers related to outcome measures that TRICARE requires: SRS-2, Vineland-3, PDDBI, SIPA, and PSI-4 short form.

But that was just the tip of the iceberg. TriWest had incomplete contract lists in every state where it administered benefits.

What did that mean? Provider directories weren’t accurate, and credentialed behavior analysts and assistant behavior analysts weren’t properly recognized as authorized providers. As a result—and through no fault of their own—thousands of providers couldn’t request authorizations, submit claims, or get paid.

These providers were forced to request and receive authorizations via fax—a highly inefficient process. Many faxes were lost in the digital ether, leading to lapsed authorizations. This led to service disruptions—with devastating repercussions for clients’ wellbeing—as well as financial instability for providers.

From the beginning, CASP has been advocating with TriWest to address these issues.

Throughout February and March, we connected bi-weekly. At that time, TriWest repeatedly assured us that every issue would be resolved by March 30. In the meantime, it escalated the concerns of individual CASP members that we brought to its attention.

Unfortunately, TriWest missed its self-imposed deadline. As a result, CASP and our members brought concerns to Congressional offices during our D.C. fly-in event in April.

We received an outpouring of support from House and Senate members. Alaska Senator Dan Sullivan was especially engaged. He hosted a roundtable with TriWest leaders and constituents to address ongoing concerns. CASP was honored to participate, and we’re grateful to Aspire Behavior Solutions, which was instrumental in scheduling the roundtable.

Afterward, CASP formally requested that TriWest provide a detailed, comprehensive status update on all areas impacting the provision of services. TriWest initially suggested that concerns had been fully resolved and asked for data to support ongoing concerns. When CASP shared the evidence, TriWest provided a comprehensive status update. It also set a new estimated resolution date of June 30.

TriWest’s continued extensions are disappointing. But we’re pleased to have received a detailed accounting of the steps it’s already taken—and the steps that remain—to resolve providers’ concerns.

Based on CASP member feedback, it appears TriWest is moving toward resolution. We continue to monitor the situation to ensure it honors its commitments. And we hope to work with TriWest on additional Autism Care Demonstration provider outreach.

We can’t thank providers enough for remaining steadfast. Your advocacy has helped move the needle. More than that, you’ve made a lasting impact on military families by continuing to serve them during challenging times.

If you’re still experiencing TRICARE barriers, please contact Mariel Fernandez, our vice president of government affairs.