Recent changes to the claims process for Tricare, the health insurance program for military personnel and their families, have caused disruptions for mental health clinics in the Hampton Roads area.
Starting January 1, PGBA LLC began handling claims for the Tricare East Region. However, a spokesperson for Humana Military, the regional contractor overseeing the East Region, told NBC News that a “small percentage” of provider records in the claims system contained outdated or incorrect data, preventing claims from being processed during January.
As a result, some local providers have reported not being paid by Tricare since the beginning of the year.
At Lighthouse Counseling in Virginia Beach, about 25% of their clients use Tricare. The clinic has stated that some of their counselors have not been paid for services provided to these clients.
Elizabeth Hunter, a licensed professional counselor at Lighthouse Counseling, shared that she has not received payment since January and estimates she is owed around $6,000. She explained that the transition to PGBA LLC’s claims processing system caused data migration issues, leading to the loss of her credentialing, which in turn affected her payments.
Hunter added that, due to the situation, her Tricare patients must now obtain a referral from their primary care manager in order to continue receiving her services. One of her clients, she said, told her it would take three months to get the necessary referral, and they couldn’t afford to pay out of pocket.
The issue continues to affect Lighthouse Counseling months after the claims system change. Meichell Worthing, the clinic’s owner, said Tricare typically represents about $25,000 in monthly revenue for the practice. With the ongoing payment delays, she said the clinic is now out of approximately $75,000. Though they received a prepayment in January to help with the transition, many counselors are still waiting for payment for services already rendered.
Clients of Lighthouse Counseling who use Tricare, like Alex Arnold, are also feeling the strain. Arnold, who doesn’t have a primary care manager to monitor his health due to lack of available providers, said, “I would almost rather go with a broken arm for eight months than go without counseling for eight months.”
In response, Lighthouse Counseling is offering its Tricare clients a new system where they prepay for services, with the practice promising to reimburse them once Tricare processes their claims.
Elizabeth Hunter emphasized the need for change, stating, “Our servicemen and women and their families deserve better. They should not be having to go through this. They struggle enough, they have sacrificed enough, and they should not have to sacrifice their mental health care because of some glitch in the system.”
10 On Your Side reached out to Humana Military for comment but has yet to receive a response.
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