Research - Rehabilitation - Re-Employment

Sgt. Shaft 06/02/2003

Dear Sergeant Shaft:
My numerous colleagues in the over-65 US military retiree community and I are deeply in the debt of a friend like you in the media who championed the successful effort to enact the "Tricare for Life" legislation. The fix has already meant much and will continue to pay potential dividends for those of us who sensed that we had "fallen through the cracks of the system".

We were told that even if we had group insurance through our employers, Tricare for Life would pick up some of the residue left unpaid by our civilian insurance. All we had to do was to sign up for Medicare Part B. Now, most medical practitioners will directly bill only the primary insurer who, by definition, is the civilian group insurer; leaving it to the patient to file with Medicare for the residue that Tricare has indicated it would cover. The Medicare point-of-contact for Virginia and other states in this area is Trailblazers Health Enterprises in Dallas, TX. My experience to date with Trailblazers is that the firm routinely disallows patient-filed claims making pass-through to Tricare impossible.

I have submitted, remonstrated telephonically, and resubmitted  [following the advice of various Trailblazers representatives] as many as a dozen claims to date. None has resulted in approval. Despite my insistent indication on the application that I was filing a second payer claim, Trailblazers has rejected them with the rationale that they should have been submitted by the practitioner, or that the information was "incorrect" despite the fact that my primary insurer had accepted the very same  information.

Fortunately, my company insurance is reasonably comprehensive [though far from perfect} and the residual claims filed for  Medicare/Tricare coverage were not oppressively large. I am, however, paying indirectly through Medicare for services I am not receiving. I wrote a letter to Trailblazers on 24 March requesting guidance on the problem and as of this date, they have not had the courtesy to respond.

I suspect that I am not alone in this quandary. It seems to me that it is unacceptable for those charged [and paid with federal tax money] with executing the intent of the "Tricare for Life" legislation to be so remiss in administering a program that has the potential for doing so much good. Anything you can do to shed light on this problem would be appreciated.

Keep up the good work!

Sincerely,
Woolf P G
Colonel, USA [ret]

Dear Col.
The following is an extract from the Medicare website: http://www.Medicare.gov/Basics/FAC.asp
"...If you are in the Original Medicare Plan, providers (e.g., hospitals, skilled nursing facilities, home health agencies, and physicians) and suppliers are required by law to file Medicare claims for covered services and supplies that you receive. You should not need to file any Medicare claims..." The Trailblazer customer service person indicated that most of the Medicare providers would file with both the primary insurance and Medicare. If the provider refuses, the patient should call Trailblazer at 1-800-552-3423. They will then help the patient file.

When coordinating as secondary coverage, Medicare is generally like TRICARE. That is, they will usually pay any remaining balance up to 115% of the allowable amount (for non-par providers). If there is problem with the claim, the Medicare Summary of Benefits also contains appeals information.

In most cases there is nothing left to pay when Tricare for life (TFL) is tertiary; therefore, neither TRICARE nor the patient has any liability after the group coverage and Medicare have paid. The patient needs to remember that the law caps provider reimbursement at 115% of the Medicare allowed amount. After the group coverage pays, Medicare will usually pay the difference between the OHI payment and the billed amount (not to exceed 115% of the allowed amount). I would have a hard time envisioning a scenario in which there was a balance owed for TFL to consider.

Unfortunately, the key is for the patient to work with the Medicare FI to make sure that the Medicare side of the bill is properly adjudicated.

Shaft Kudos
Hats off to Rep Howard Coble (R ) NC for his remarks made on Januaary 7 “ On March 25 of this year, Mr. Speaker, I came to the House floor and said the following: ``Many insist that this is a unilateral operation. Not true. There are many supporters, but they are reluctant to openly oppose Saddam. They fear him. They, in fact, Mr. Speaker, are afraid. Many of his neighbors loathe Saddam, but they stand in fear. But the Bush-Blair wagon will move forward with the support, albeit sometimes anonymous, of other nations.''

Mr. Speaker, as we have continued to praise our U.S. troops, I want us to avoid ignoring our allies, because as I said on this floor about 2 months ago, it is not a unilateral effort. I recently read in the Sergeant Shaft article, which appears regularly in the Washington Times, a letter from an Australian commander who wrote, ``When are the British and Australian troops going to be included in the television coverage?''

A fair question. Now, I am not critical of the coverage, Mr. Speaker, as it is only natural to praise our own troops first, but we certainly do not want to turn deaf ears to the contributions of our allies, Great Britain, Australia, Spain, Poland, many others.

I was recently in Denmark regarding the sensitive issue of maritime security and learned while there of the impressive assistance we have received from the Danes in this war effort. 

Send letters to Sgt. Shaft, c/o John Fales, P.O. Box 65900, Washington, D.C. 20035-5900; fax to 301-622-3330; call 202-462-4430 or email sgtshaft@bavf.org.

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