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Civilian health insurer goes after retired soldier

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Posted: Friday, May 5, 2006 12:00 pm | Updated: 3:16 pm, Wed Aug 15, 2012.

By Debbie Stevenson

Killeen Daily Herald

Ten years into retirement, Master Sgt. Bobby Jones has found himself caught between two insurance companies and a law that says the military has to bill him.

However, inquiries by the Herald into his dilemma apparently have helped him toward a resolution.

In 1995, Jones retired from the Army at Fort Hood.

Like many retiring soldiers before him and since, he elected to retain his military health care coverage under Tricare.

Jones signed up for what is known as Tricare-standard, which meant he now had to pay 30 percent of the bill for seeing doctors approved by Tricare and 50 percent for outside providers. Prescriptions filled off post were now $30 for generic prescriptions if filled off post, and free if filled at a military hospital.

Retiring in Killeen, Jones chose to fill his prescriptions at Carl R. Darnall Medical Center's pharmacy at Fort Hood although he had other insurance coverage.

Jones, who had been working part time for Wal-Mart in Round Rock while on active duty, continued with the store after retirement as a full-time employee. As a result, he obtained health insurance through the retail giant with Blue Cross Blue Shield, based in Chicago. The civilian coverage did not offer prescription coverage unless the medication was given during a hospital stay.

The second insurance was necessary, said his wife, Mariti, because going into retiree status meant the family was now a lower priority for the military behind active-duty soldiers and their families.

Being bumped to the end of the line and placed on waiting lists with Tricare and Darnall was a problem for the couple because they were caring for a child with cerebral palsy, Mariti said. Plus, both she and her husband have heart conditions.

"We're grandparents raising grandchildren," she said. "We had to have, under the court order, we have to have insurance on him (the disabled grandson) at all times as part of the custody agreement.

"With a disabled grandson, you just can't wait on them to give you an appointment," she said.

All appeared to go well with the dual coverage – until July 5, when Bobby filled a prescription at Darnall.

With the military and Tricare mandated by law to be the insurance of last resort, Darnall attempted to recover some of the cost from Bobby's private insurance. The insurer paid 50 percent of the claim because Darnall was considered an "outside" provider. Darnall absorbed the rest.

Subsequent claims and payments continued through February. The bills sent by Darnall to Blue Cross Blue Shield totaled $1,095.44. According to copies of the explanation of benefits sent to the Jones family, Blue Cross-Blue Shield paid $481.30 to Darnall.

But it seems someone in Chicago had assumed the claims filed by Darnall were for inpatient stays. With the family's frequent trips to the hospital, the error might not have been discovered if a middle initial typo on an explanation of benefits had not been questioned by Mariti. Her call to see if the claim actually belonged to them prompted Blue Cross Blue Shield to review their file.

The investigation revealed the claim was indeed for Bobby and Mariti. But now, Blue Cross Blue Shield had discovered it should have denied the out-patient prescription claims and is aggressively trying to get its money back.

With no response so far from Tricare or Darnall, Mariti said the private insurer has come after the family for the money.

"They say it's our responsibility to ensure they get their money back," said Mariti, who spent three hours on the phone with all three parties Thursday, to no avail.

The beneficiary is not responsible, said Phillip Washburn, Darnall's public affairs spokesman at Fort Hood.

"If a billing error is made by the hospital, the hospital and insurance company will sort out the problem. The patient is not responsible," Washburn said. "If monies are incorrectly paid to the hospital and a refund to the insurance company is necessary, the refund will be paid by the hospital."

Blue Cross Blue Shield media relations in Little Rock, Ark., did not return calls seeking comment.

It even has gone one step further in adding to the family's health-care complications, Mariti said.

"They're saying we're now having to get everything pre-approved," Mariti said.

On the military side, Washburn said the hospital had a representative briefed and ready to help the Jones family deal with their billing issue.

"We're going to get this thing taken care of," Washburn said after attempts were made to contact the family late Thursday afternoon via telephone.

A spokeswoman at Tricare headquarters in Falls Church, Va., also confirmed Thursday that Blue Cross Blue Shield should pursue the billing issue with Darnall and not the beneficiary.

"Billing errors are sorted out between the MTF (military treatment facility) and the billed insurer," Kerry Humphrey stated in an e-mail that outlined the laws and policies covering Tricare and private insurance.

Washburn emphasized patients also are not "responsible for any co-payment or deductible when the services are provided and billed by Darnall or any other military treatment facility."

"These costs are absorbed by the government," he said.

If they do encounter problems with Darnall, Washburn said beneficiaries should contact Darnall's Uniform Business Office at (254) 288-8693.

Tricare insurance claims are in a totally separate system administered by Humana Military Healthcare Services, he said.

Humphrey said beneficiaries also can contact Darnall's higher command if they do not receive a satisfactory response from Darnall.

"Army Medical Command, Fort Sam Houston, Texas, is the management element that has business office oversight of Darnall," Humphrey said. "Billing issues unresolved by the commanding officer, Darnall Community Hospital, can be referred to Army Medical Command, which is located in San Antonio."

Contact Debbie Stevenson at deborah@kdhnews.com

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