Pentagon officials circulated a memo to military leaders on Thursday blaming delays to military families’ health care referrals on UnitedHealth Group, the nation’s largest private insurance provider. The delays led the Defense Department to take the unusual step of granting temporary waivers “so the plan’s members in the western region could get specialty care without UnitedHealth’s authorization and not incur penalties.”
In April, UnitedHealth took over a contract that serves beneficiaries enrolled in the Tricare Prime program in the western United States. Tricare ensures that nearly 10 million active duty personnel, retirees, reservists and their families have access to health benefits; the Tricare Prime program itself is a subset of that entitlement, pairing beneficiaries with “a primary-care manager responsible for referring patients to specialists for necessary services.”
However, those specialist referrals are contingent on the insurance provider’s — in this case, UnitedHealth’s — approval. The trouble is, the insurer has been falling behind in approving those referrals, leaving many military families in limbo while waiting for their care. And while UnitedHealth spokespeople claim they were simply overwhelmed by an unexpected number of referral requests, others argue that they were aware that this exact problem would arise, and should have been prepared to deal with it:
The delays are occurring because UnitedHealth has received requests for referrals and care authorizations that “far exceeded the norms” since it took over the contract, said Bruce Jasurda, a spokesman for the company.
“The increased volume was driven largely by people asking whether previously authorized referrals and authorizations were still valid, resulting in large numbers of duplicate referrals in the system,” Jasurda said in a phone interview. The company “understands the issues we need to improve on, and we are taking aggressive action.” […]
U.S. Representative Doug Lamborn, a Colorado Republican, said in a letter to Defense Secretary Chuck Hagel yesterday that health-care providers in his state are facing “unexpected and dramatic reductions in their workload” because of the backlog in referrals. He also blamed UnitedHealth.
“They claimed to be aware of the problem and doing what was necessary to get on top of the problem,” Lamborn said in a phone interview. “There seemed to be a disconnect from the reality on the ground.”
Specialty care encompasses a broad swath of medical services, ranging from urgent care surgical procedures to treating autoimmune disorders — so UnitedHealth’s delays were, in essence, preventing military families from getting anything other than primary and preventative care until Thursday’s Pentagon waiver was issued. That’s especially problematic considering that many military families’ health needs fall outside the realm of primary care.
And when it comes to Tricare, specifically, beneficiaries certainly don’t need additional hassles from insurance companies. The program’s outsized spending on retiree — as opposed to active — enrollees’ benefits has led Pentagon officials to call for raising veterans’ out-of-pocket health costs. So far, Congress has found such a proposal too politically unpalatable to adopt — but given the reality of the numbers, their resistance may not last much longer.