Health Care Delivery in TRICARE (United Healthcare)
Introduction
TRICARE is a uniformed services health care program under the umbrella program of United Healthcare that is offered for active service duty members together with their families as well as retired service members with their dependents and members of the National Guard and Reserve with their families and other eligible survivors. The main objective of TRICARE is to deliver world-class health care services and benefits for all the Military Health System (MHS) beneficiaries. It also aims at providing the highest level of satisfaction of its patients and bringing together all the networks of civilian health care services for pharmacies, institutions, professionals and suppliers together with health care resources of the uniformed services. This it aims to achieve as it maintains its capability to continue supporting military operations. The TRICARE program is available worldwide and in the United States it is divided into 3 groups: TRICARE North, South and West which are all jointly managed by the TRICARE Management Activity (TMA) and the TRICARE Regional Offices. TMA is contracted with civilian managed care support contractors the three regions to aid the military treatment facility (MTF) and TRICARE regional directors.
Laws, Policy and Regulations
All the contracted TRICARE providers are under obligation to follow all the procedures, rules, programs and policies. The TRICARE Policy and all of the statutes governing the TRICARE Program are in the Chapter 55 of Title 10 of the Code of Federal Regulations of United States together with Title 32, part 1099 of the United States (CFR). Through the TMA, the Department of Defense (DoD), directs United Healthcare its umbrella health facility service on the effective administration of the TRICARE program through modifications to the CFR.
The TRICARE Policy Manual, TRICARE Operations Manual and the TRICARE Policy Manual together with the TRICARE Reimbursement Manual are often continually updated to reflect all the changes in the CFR. However, this often depends on the complexity of the law as well as the federal funding as it may take a year or more before any direction is given from the DoD through the United Healthcare and TMA. Some of its significant policies include the Health Insurance Portability and Accountability Act of 1996, (HIPAA Privacy Rule, Security Rule, Transactions and Code Sets Rule, Employer Identifier Number and National Provider Identifier.
Provider Certification, Credentialing and Certification
Certification
TRICARE has the goal of ensuring that most of its providers are certified. The PGBA is often responsible for conducting the process of certification that includes the assigning a TRICARE ID number to all of its providers. All providers certified by TRICARE are allowed accurate 1099 tax that reports to the IRS. Certified providers are considered non-network providers. All the behavioral health care providers, providers in Alaska, skilled nursing facilities and providers who are not Medicare-certified are always expected to must complete and submit their certification forms to ensure that PGBA processes their claims.
Credentialing
In addition to becoming certified, all providers who are interested in signing a contract to become members of the TRICARE network are usually credentialed by the United Health care. The process for credentialing often involves the obtaining of board certification, professional background, and primary-source verification of the education of the provider, license, malpractice history as well as other pertinent data. As a result, a provider whose credentialed, certified and has signed a contract is considered a network provider after a final notification of the execution of the contract by the United Health care.
Accreditation
TRICARE is accredited by the Authority 32 CFR 199.6 (c) which specifies that health care providers should graduate from regionally accredited universities or colleges. This consequentially means that the education programs to be offered by the university ought to be recognized by the Council on Higher Education Accreditation (CHEA). Any approval by a state agency of the government is often not acceptable for accreditation.
Data Sets in TRICARE
The Records Management System supports all of the Health Affairs of the TRICARE Management Activity (HA/TMA) to ensure there is proper use, maintenance and disposition of electronic as well as paper records that is in accordance with regulations, federal laws and the DoD guidance that regards the protection of sensitive health data. HA/TMA employees in TRICARE has federal records management responsibilities of maintaining active programs on the continuous management of records. There are three main data sets in TRICARE:
- MHS Data Repository (MDR)/Management Analysis and Reporting Tool (M2) which is the most common used system for research containing purchased and direct data, MTF accounts data, staffing, clinical and other data files. It is mainly used for the comprehensive data warehouse.
- Expense Assignment System (EAS) that contains summary time staffing data for expenses, obligation and financial accounting.
- Mental Research File which contains data on Theater Medical Data System, Contingency Tracking System, Defense Manpower Data Center, as well as other auxiliary data sets for psychological health research.
Types of Data Records in the MHS
TMA manages and maintains most of its comprehensive health data on over 9.5 million of its beneficiaries in numerous databases. Initially most of the data files were paper work but with the advent of the electronic systems there was a major and swift shift that saw TRICARE set up numerous online databases that were easily accessible and efficient in health care delivery. The Electronic Health Records (EHR) now used provides clinical care quality benefits and important data elements necessary for research. Some of the challenges TRICARE faced during the shift included a massive losses of critical data that were all on paperwork and were yet to be decoded and digitized, however all this was recovered for with the current efficient and versatile online system.
Funding
TRICARE is mainly funded by the Joint Incentive Fund (JIF) which is under the Section 721 of FY 2003 National Defense Authorization Act (NDAA). It provides incentives for the creation of innovative DoD/VA sharing initiatives at TRICARE in its regional and national levels. DoD and VA, for instance, contribute $15M each to the Fund in FY04 with a similar amount being deposited to the fund at the beginning of every fiscal year through FY 07. The Joint Incentive Fund program is managed by the NDAA 2010.
Revenues
TRICARE revenues consist of:
- Insurance premiums that assume the underwriting risk for costs of civilian health care services that are usually delivered to all eligible beneficiaries;
- Health care services that are provided to beneficiaries that are always in turn reimbursed by the federal government;
- ASO fees that are related to claim processing, enrollment, disease management, customer service and other services.
- Insurance premiums are also always considered as revenue over the period of coverage provided.
- Reimbursements from the health care services are furthermore recognized as revenue during the period of health care services provided.
- Administrative service fees are also not left out as revenue in their period of services.
Reimbursements
TRICARE Reimbursement Methodologies and rates are subject to applicable modifiers fitting the description of service. The reimbursement limit is 100% whereby all the payments to network operators of all medical services that are rendered to TRICARE. The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) similarly has a maximum allowable charge (CMAC)which is the maximum amount TRICARE reimburses for all the nationally established procedure coding like the codes for professional services. CMAC is essentially the TRICARE-allowable charge that is offered for all services covered when it is appropriately applied to services that are priced under CMAC.
Coding
The Unified Bio-statistical Utility (UBU0 consists of service coders who work together towards the development and publishing of the Department of Defense (DoD) coding guidelines. The following are some of the guidelines that are available for references to MHS personnel when they are coding patient care in the MHS information systems. There are guidelines for coding specialty and professional services and inpatient institutional services that are divided into: diagnostic, procedural and evaluation and management coding. Diagnostic coding describes the clinical picture of patients and non-medical reasons for causes of injury and seeking care. The procedural coding is also called the Healthcare Common Procedure Coding System that has two levels that cover most of the care services and procedures.
Quality Improvement
Quality Improvement Programs by the DoD are usually administered every fiscal year and ensure that MHS has effective patient safety programs and comprehensive quality management systems. Other areas under observation also include resources, leadership, patient safety oversight and quality across the continuum.
Utilization Management
In TRICARE, the main goal of its UM program is to ensure the maintenance of the efficiency and the quality of its health care delivery through caring for all its patients at appropriate levels. This also ensures that the most effective treatment plans are administered under nationally acceptable clinical guidelines of practice.
Roles of Health Information Professionals in TRICARE
Apart from ensuring that all reimbursement claims statement of services is duly submitted to third-party-payers, HIM professional have a wide range of roles in TRICARE that include the following:
- Ensuring that all the health records documents support the services that have been billed
- Appealing for all the insurance claims denials
- Applying for coding guidelines and editing the assigned codes for coding accuracy and quality
- Assigning procedural and diagnostic codes depending on patient record documentation
- Clarifying missing or ambiguous documentation.
