1/25/2025 0 Comments Providers Serving TRICARE West Military Communities- Understanding the TriWest Healthcare Alliance TransitionThe military healthcare landscape is undergoing a significant transformation with the transition of TRICARE West services from Health Net Federal Services (HNFS) to TriWest Healthcare Alliance. This shift impacts clinicians serving military members, veterans, and their families across 26 states, presenting both challenges and opportunities. As a clinician, military spouse, and advocate, I am committed to providing accurate information to help our community navigate this transition effectively and confidently.
On Thursday, December 26, 2024, I had the opportunity to meet with Mr. David McIntyre, CEO of TriWest, and Ms. Donna Hoffmeier, Senior Vice President of Strategic Communications & Advocacy. Our discussion centered on the recent transition of TRICARE West Region services from HNFS to TriWest Healthcare Alliance. This significant change presents both challenges and opportunities for providers and beneficiaries alike. Transitions of this scale are undoubtedly complex, but TriWest’s leadership emphasized their commitment to minimizing challenges and ensuring uninterrupted care. While my ongoing interactions with TriWest leadership suggest they are working diligently to uphold their positive intentions, significant concerns persist among providers as the process unfolds. Many express worries about the potential impact of operating without contracts, delays in payment, and a lack of communication, which has led some to consider discontinuing their work with TRICARE. These concerns are amplified by a history of administrative inefficiencies and communication failures within the TRICARE system. The complexity of navigating TRICARE’s website further complicates the experience for both providers and beneficiaries, often leaving critical questions unanswered. Long wait times for customer support, coupled with inconsistent or inaccurate responses, have eroded trust and added frustration. For providers, this has translated to delays in securing essential information, confusion over updated processes, and difficulties maintaining a seamless care experience for their patients. Beneficiaries, in turn, have experienced appointment cancellations, delays in obtaining referrals, and extended wait times to access care. Much of this could be mitigated by the Defense Health Agency (DHA) taking greater responsibility for the issues at hand, releasing a clear plan to address the current challenges, ensuring payments are being executed properly in both regions, and keeping contract execution on track to meet the 90-day waiver deadline set by the DHA. These cascading issues highlight the urgent need for clear communication, streamlined systems, and robust support to rebuild confidence and ensure that providers can continue delivering high-quality care. It is important to clarify that TRICARE is overseen by the Defense Health Agency (DHA), a division of the Department of Defense (DoD). The DHA is responsible for establishing the policies, guidelines, and regulations that govern TRICARE operations, ensuring compliance with federal laws and alignment with military healthcare standards. Contractors, such as TriWest, are tasked with administering TRICARE programs within specific regions. Their responsibilities include managing provider networks, processing claims, and delivering customer support. Although their names are similar, it is important to note that TriWest functions under the oversight of TRICARE and is responsible for implementing its policies and managing the program's operational aspects. Key Challenges and Provider Concerns Continuity of Care Providers are increasingly concerned about operating without contracts, delays in payments, and the potential for disruptions in patient care. These challenges have led to discussions among clinicians about the possibility of discontinuing their work with TRICARE, raising alarms in both the provider and beneficiary communities. This is especially troubling given the widespread acknowledgment of an existing shortage of providers, particularly in specialized areas of care. A recent survey (December 2024) of mental health providers, primarily in the Colorado area, shared with TriWest leadership, highlighted the following insights:
Among providers who have fully completed credentialing:
Within this group of providers accepting new clients:
These findings underscore the concern that there are currently insufficient in-network providers to meet the needs of beneficiaries. Communication Issues A history of administrative system failures and inadequate communication with both providers and beneficiaries has eroded trust. The complexity and layered structure of the TRICARE website often makes it difficult to navigate and locate accurate or relevant information. Both providers and beneficiaries face long wait times when trying to reach support, often receiving little to no helpful information or inconsistent and inaccurate responses. For beneficiaries, these challenges have resulted in uninformed providers, canceled appointments (sometimes after patients have been waiting months to be seen), and confusion about the referrals process. These issues compound frustrations and further erode confidence in the system. Stipulations for TRICARE Prime and Select Beneficiaries To help clinicians guide their patients during the transition, here are key provisions based on their plan type: For TRICARE Prime Enrollees If the provider is a TRICARE network provider:
If the provider is no longer a TRICARE network provider:
For Care Not Requiring Pre-Authorization Patients may keep seeing their provider and pay TRICARE Prime copayments. Starting April 2, 2025, if the provider is still a non-network provider, the patient may have to pay point-of-service fees and file a claim when seeing a nonparticipating, non-network provider. *Point-of-Service (POS) option allows TRICARE Prime beneficiaries to receive nonemergency care from any TRICARE-authorized provider without a referral from their Primary Care Manager (PCM). While this offers greater flexibility in choosing healthcare providers, it comes with higher out-of-pocket costs. Key aspects of the POS option include:
For TRICARE Select Enrollees Starting January 1, 2025 If you are a TRICARE network provider:
If you are no longer a TRICARE network provider:
For Care Not Requiring Pre-Authorization: Beginning January 1, 2025, patients who access care from you as a non-network provider will likely face increased out-of-pocket costs. They may also be required to pay upfront and file their own claims for reimbursement. Provider Resources and Support To assist clinicians during this transition, TriWest offers the following resources: Joining the Network Providers can join the TRICARE network by: 1. Completing the "Join Our Network" form 2. Submitting required credentialing documents. 3. Completing the contracting process. Claims Submission Options
*Please be advised that the current TriWest states the following about payment turnaround time: "TriWest will make best efforts to process Clean Claims within thirty (30) days of receipt and will make payment directly to Provider for Covered Services rendered by Provider to Beneficiaries in accordance with the terms of the Reimbursement Exhibit." * Portal Services (Availity)
Supporting Providers and Holding the DHA Accountable The transition of TRICARE West services to TriWest represents a pivotal moment in military healthcare, presenting both challenges and opportunities. For providers, this change highlights the importance of proactive engagement and self-advocacy to ensure uninterrupted care for members and beneficiaries. By staying informed about evolving policies, addressing potential issues early, and maintaining open communication, providers can play a vital role in mitigating disruptions and maintaining the high standard of care on which military individuals and families rely. As TRICARE is directly managed by the Defense Health Agency (DHA), the agency must appropriately be held accountable for addressing systemic gaps, improving communication, ensuring that contracted entities have the necessary resources to execute their contracts effectively, and overseeing that these contractors fulfill their obligations successfully. Accountability also includes ensuring timely payments to providers, as delays in payment exacerbate provider frustration and jeopardize the continuity of care. Additionally, the DHA must rebuild trust within both the provider and beneficiary communities by providing transparent, consistent, and timely updates to reduce confusion, prevent delays, and support stakeholders in navigating the system effectively. Failure to fulfill these responsibilities risks worsening access to care for beneficiaries as frustrated providers may choose to disengage from the system altogether. The success of this transition depends on a collective effort to hold the DHA accountable for resolving systemic issues within TRICARE, demand improved communication, and advocate for political support to ensure meaningful reforms. By stepping into this role, providers can drive the development of a stronger, more responsive healthcare system that benefits all stakeholders. Web Resources
Author: Dr. Courtney Barber, PsyD, LMFT, AAMFT-S --- *Note: This document reflects information as of January 25, 2025 and will be updated as new developments occur. *
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AuthorDr. Courtney Barber is a Psychologist and Licensed Marriage and Family Therapist with over 22 years of experience in the healthcare field. As the founder and owner of Barber Family Counseling & Wellness, she provides essential mental health and wellness services across Colorado and Nevada. A dedicated advocate for accessible mental health services, Dr. Barber is passionate about improving community well-being and addressing disparities in mental health care access. She is particularly committed to advancing military access to care, ensuring service members and their families receive the mental health support they need. Her expertise spans clinical practice, organizational psychology, and workplace well-being, empowering individuals, families, and organizations to achieve resilience, personal growth, and professional success. ArchivesCategoriesThis website uses marketing and tracking technologies. Opting out of this will opt you out of all cookies, except for those needed to run the website. Note that some products may not work as well without tracking cookies. Opt Out of Cookies |
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