Tricare Cap/DME Reimbursement Analysis & Recovery

What is Tricare?

Tricare, formerly CHAMPUS, is the insurance for uniformed service members, retirees, and their families. When service members and their families receive services outside the Department of Veterans Affairs, they receive their benefits from a Tricare Prime contractor. Hospitals usually experience 1% or less of their patient volumes from the Tricare program. While many of Tricare’s reimbursement methodologies closely follow Medicare, having experts familiar with Tricare specific nuances can be essential to hospitals seeking full reimbursement.

Healthcare Reimbursement Solutions (HRS) has dedicated specialists focusing on the identification and recovery of Tricare Capital & Direct Medical Education (Cap/DME) reimbursement for hospitals throughout the U.S. and Puerto Rico. HRS staff and principals have been assisting hospitals since 1996 and have directly been responsible for more than $500M of additional recovery paid to hospital providers.

Benefits of Choosing HRS:

Tricare Capital & Direct Medical Education (Cap/DME) reimbursement for hospitals

  • Healthcare Reimbursement Solutions LLC (HRS) has dedicated specialists focusing on the identification and recovery of Tricare Capital & Direct Medical Education (Cap/DME) reimbursement for hospitals throughout the U.S. and Puerto Rico.
  • HRS has developed proprietary databases that consist of Medicare HCRIS data and Tricare Cap/DME payment and recoupment history, creating a detailed picture of reimbursement recovery opportunities.
  • Our research and analysis provide valuable insight by identifying the specific hospitals and fiscal years where opportunity resides.
  • Tricare Cap/DME reimbursement is an often overlooked area of third party reimbursement, and hospital staff can rarely spend the time necessary to recover all of what is available. We have the expertise and knowledge needed with Tricare Cap/DME Reimbursement Analysis & Recovery.
  • HRS staff and principals have been assisting hospitals since 1996, and have directly been responsible for more than $500M of additional recovery paid to hospital providers.

Recovery opportunities primarily result from correcting underpayments that occurred originally or arose after payment of the initial Cap/DME request. While Tricare mirrors many of reimbursement methodologies after Medicare, there are differences, including the need to file a Capital and Direct Medical Education reimbursement request annually.

Recovery opportunities include the following:

Amended Requests

Most hospitals are unaware that there is no statute of limitations for amending Cap/DME requests. Amended Cap/DME requests should be filed after a new Medicare Notice of Program Reimbursement (NPR) is issued for a fiscal year for which an initial Cap/DME request was paid. HRS’s databases track and identify fiscal years where a new Medicare NPR was issued and the newly NPR’d Medicare Cost Report results in Capital and/or Direct Medical Education Costs increasing from the initial Cap/DME request (or the most recent amendment). This means that if a Medicare Cost Report for a fiscal year ten years ago is newly NPR’d, the hospital should file an amended Tricare Cap/DME request. HRS databases accurately calculate the reimbursement recovery opportunity related to the new NPR.

Initial CAP/DME Requests

Tricare reimbursement regulations change on a regular basis. Changes first appear in the Federal Register (FR) and then the Tricare Reimbursement Manual (TRM). Most hospital reimbursement managers do not have the time to read the FR or TRM for reimbursement changes related to Tricare.

Recent changes have been issued relating to Sole Community Hospitals, Rehabilitation Hospitals, and Long-Term Hospitals. Many of these hospitals won’t become aware of the regulation changes that favorably affect their reimbursement until several years have passed, and reimbursement has been lost.

Additionally, HRS has identified where a Tricare Contractor misinterpreted TRM regulations, which led to the improper stoping of payment for a specific add-on component to DME. HRS is working with Tricare and the contractor to resolve and correct this error.

Regulation Changes

Although most recovery opportunities are retrospective, many hospitals partner with HRS to prepare the initial Cap/DME requests. HRS ensures the requests correctness, timely filing and receipt, and tracks the submission until paid. Hundreds of hospitals miss the twelve-month filing deadline every year. If a hospital misses the twelve-month deadline, they permanently lose the right to reimbursement related to that fiscal year.

Stale Dated Checks

If a hospital does not cash a check within six months of receiving it, it becomes stale-dated. HRS uses its databases to identify such Tricare “stale dated” Cap/DME checks. There are many reasons why this happens, but Tricare does not notify the hospital when a check stale dates. The onus is on the hospital to identify the issue and send in a written request for re-issuance. In the last 20 years, over $40 million in Cap/DME checks have stale-dated and only about $8 million have been reissued. There is a six-year statute of limitations to request a reissue of a stale-dated check.