Providers, Staff, and patients share concerns and some confusion regarding EFM’s decision to terminate its contract with TriWest. What follows is an in-depth explanation of the process underlying that decision. It will take a bit to get through. But if understanding our decision is important to you, this context is important.
On October 31, 2021, Evergreen terminated its contract with TriWest Community Care Network, administered by Health Net. Any decision that impacts the care of Veterans is emotional and requires explanation. I sent letters of explanation to all affected patients and EFM providers.
That letter also explained the rationale regarding EFM’s approach to providing health care for Veterans with benefits available through the Veterans Administration. In that discussion, I explained the pitfalls of having two Primary Care Providers from different organizations with poor communication between those entities.
Prescription errors due to inaccurate information, the lack of sharing diagnostic studies, and critical decision-making made such care difficult. I noted that these Veterans have either Medicare or Tricare and that we take both insurances. However, the patient would be best served by choosing to receive their care through EFM or the VA system – not both.
I started with these observations:
Many current EFM providers have served in the military.
All EFM employees greatly respect and appreciate those who have served in the military.
Some Veterans have limited income and benefit from Veteran Administration services or medications they otherwise could not afford.
I provided some definitions and regulations taken from the government’s VA official site.
TriWest Healthcare Alliance (TriWest) was founded in 1996 to provide active-duty service members, retirees, and their families access to quality health care under the Department of Defense Tricare program
TriCare– For Active-Duty Service Members, National Guard/Reserve, and Their Families Covers those who are currently serving in the U.S. Armed Forces, and their family’s Military retirees are also TRICARE-eligible (dual eligible) Program falls under the Department of Defense Receives funding through the defense budget. You never bill TRICARE for a Veteran with a TriWest authorization.
At the age of 65, Tricare converts to a Medicare supplement. To continue Tricare coverage at age 65 and beyond, you must have Medicare Parts A and B so that Tricare can supplement Medicare.
You can have both Medicare and VA benefits, but Medicare and VA benefits do not work together. Medicare does not pay for any care you receive at a VA facility – and VA benefits will not pay for Medicare deductibles or copays.
EFM has always taken Tricare. It pays poorly – the lowest of all payers and considerably less than Medicare. Referrals are cumbersome. The billing process is slow and difficult, with many denials. We accept it only so we can serve these veterans.
On June 6, 2018, President Trump signed the VA MISSION ACT. It was intended to allow veterans access to community health services. To administer this, 6 Community Care Network Contracts are assigned to different providers based on region. We are Region 4. On August 6, 2019, the VA awarded TriWest Healthcare Alliance the contract to administer the Community Care Network in our region.
TriWest is a third-party payer responsible for building and maintaining a network of community health care providers, paying claims, and providing customer service under the CCN contract. This is a Coordinated Care Organization, like UHA or Trillium, funded by the Federal Government.
But TriWest didn’t manage the plan. They contracted with Health Net to do so. It became a plan under a plan with layers of bureaucracy.
To participate, Evergreen Family Medicine (EFM) needed to sign a contract to join the Community Care Network (CCN). This contract included Tricare's noncompetitive rates and magnified the complexities and process burdens. Watch how a good idea was utterly ruined by its implementation.
Questions and Answers (information is from the CCN website):
1. How can EFM see a patient under this CCN?
Answer: They must be preauthorized according to TriWest criteria:
Veterans’ eligibility to use their Choice Card in the private sector is determined by the
VA using the following criteria:
The closest VA Medical Center (VAMC) or Community-Based Outpatient Clinic (CBOC) with a full-time Primary Care Manager is greater than 40 miles from their home choice 40 miles or distance eligible facility.
They are, or will be, on a waitlist of 30 days or more with a VAMC-Choice 30-day
Services are not available at VAMC-Choice First.
The closest VA medical facility is not easily accessible from their home or has significant geographic barriers.
To avoid claims denials, all care requires authorization from TriWest before services are rendered. If a provider renders care without authorization, he/she risks losing reimbursement
2. How is a patient scheduled?
Appt scheduling and authorization process:
Veteran calls TriWest to confirm VCP eligibility
Or
VA sends referral to TriWest
PSR locates PC3 provider
PSR makes appt. on behalf of the veteran
TriWest sends authorization to the provider via fax
To avoid claims denials, all care requires authorization from TriWest before services are rendered. If a provider renders care without authorization, he/she risks losing reimbursement
Process for each visit is the same.
3. How does EFM bill?
TriWest uses WPS MVH to process all claims and can accept electronic claims through your clearinghouse/billing service or Availity. Availity's Basic Clearinghouse option allows providers to submit claims without an additional charge to the provider. WPS requires providers to pre-enroll with WPS and enroll with their clearing house for electronic transactions.
Providers will not be paid for services rendered without prior authorization from TriWest. Be sure to submit a Secondary Authorization Request and receive the approval for care PRIOR to providing services!
(This warning is repeated in each section.)
4. What else would require prior authorization?
Everything. Any advanced imaging, hospitalization, or referral to a specialist.
5. Other patient requirements:
All medications must be obtained from a VA pharmacy
6. Other burdens on the provider?
The contract allows CCN to monitor customer service and requires the designation of high-performing preferred providers that meet specific quality and performance metrics.
This translates to much reporting burden on providers and staff to meet special VA metrics.
Also, VA staff will refer to community providers and schedule care visits. Each visit requires preauthorization.
EFM conclusions:
TriWest is a 13-state CCO that won a federal contract and then outsourced its management to Health Net. However, it continued with its poor payment schedule and onerous prior authorizations. These disrupt our usual billing and scheduling mechanisms and require substantial reporting and metrics. Veterans would only be eligible when their own clinics are too full, making coordination and continuity of care problematic.
EFM Policy affirmed by Board in Oct. 2021:
If Veterans have Medicare, we can see them under that insurance. They will be responsible for the usual deductibles and copays.
We will continue to see Tricare patients as we always have.
We will issue a letter to such veterans noting that we are not part of the Community Care Network through TriWest and will not bill that insurance.
If patients desire care through an EFM provider, we must see them regularly as we would other patients (rather than awaiting a crisis moment when they present with no background information).
What Changed?
Regence replaced Health Net as plan administrator on 1/1/25. This is still a plan under a plan with layers of bureaucracy.
Regence contacted EFM, asking that we accept TriWest and promising improved processes.
EFM agreed to give this plan a trial with the stipulation that we would not function under the Community Care Network requirements listed above. These folks were either our patients or not. If they were our patients, we needed to follow them longitudinally and be allowed to coordinate care with specialists.
How did that work out?
Terrible. EFM referral and Prior Authorization personnel reported zero success in their referral and prior authorization process.
There have been no approvals, feedback, or responses. Personnel have attempted to work through the portal, faxes, phone calls, and emails, but there has been no answer.
EFM contacted Regence, but Regence stated they were unable to help. We had to go through TriWest.
We met with TriWest. TriWest stated they had outsourced this to another third party called Availity. We would have to work with them.
The TriWest web portal was not functional. Only one EFM provider was listed, and when her name was clicked on, the portal kicked the referral staff out. There was no way to access the portal.
We finally met with TriWest IT, who would “walk us through” using their web portal. It was a short time before TriWest personnel realized their portal didn’t work—it still doesn’t.
For the few referrals made, presumably through our fax, as EFM never received feedback, most were erroneous. For example, a referral to Dr. Lee in Portland was certified for some doctor at Travis Air Force Base in California.
The letters received by the patient that authorized or “certified” a referral stated plainly in bold language for the specialist office that the fact the visit was certified did not constitute assurance payment would be received.
Predictably, local specialists are not accepting referrals with this insurance under these conditions.
EFM Action:
EFM gave TriWest a 60-day notice of termination at the end of January 2025. We will continue to see these patients through 3/31.
EFM Women’s Health will continue to follow up with pregnant patients through delivery and postpartum follow-up.
EFM informed TriWest and Regence that we would reevaluate our decision when their referral process was functional and when specialists would accept that insurance and accommodate our patients' needs.
This does not affect patients with Tricare whom EFM will continue to serve.
EFM will not accept new patients covered under TriWest.
However, we will continue to provide care for existing patients whose health coverage was shifted from TriCare to TriWest on Jan 1, 2025.
Conclusions:
EFM’s experience is not unique. TriWest has been flooded with complaints. Rep. Marilyn Strickland, D-Wash, said beneficiaries are experiencing “unending delays in reaching TriWest customer service, inoperable or overloaded websites unable to process payments, and an incomplete network of providers.
A website search confirms a storm of patient complaints about the above issues.
In 2020, TriWest agreed to pay 180 million to resolve overpayments from the Department of Veterans Affairs for administering the Veterans Choice Program.
The settlement marks the second time in 8 years that TriWest has settled with the Justice Department over its federal health care contract management.
In 2012, TriWest paid $10 million amid allegations that the company defrauded Tricare by billing the government higher rates than the company had negotiated with health care providers.
The EFM decision has nothing to do with compensation or commitment to our veterans. Rather, it acknowledges our inability to coordinate quality care under this system. We will not enable or participate in an incompetent system.
When the process is functional, EFM will reevaluate this decision. EFM cannot fix this broken system, but our staff faces the wrath of disadvantaged patients.
It is critical to differentiate between Tricare and TriWest. TriWest is a third-party contractor in Phoenix, Arizona, that works with the U.S. Department of Veterans Affairs to manage health benefits. TriCare is the uniformed services healthcare program for active-duty service members and retirees.
On January 1, 2025, TriCare moved TRICARE Prime enrollees to the TriWest system. Patients currently under Evergreen Family Medicine provider’s care as a TriCare patient abruptly fell into a category of Insurance (TriWest) EFM was not accepting. This is not fair to those families.
Therefore, EFM will continue to provide care for established patients previously seen under TriCare insurance who are now under TriWest insurance.
EFM continues to see all patients with Tricare for life insurance.
Tim Powell MD
CEO, Evergreen Family Medicine