May 2025 Tricare West Transition Update
Tricare clients.
As we have received no updates on our status from TriWest we reached out this morning for an update and received some very concerning news about the latest policy. As of May 1st, if Tricare does not send us an updated contract and we have it signed and returned by May 1st your appointments will not be covered by Tricare without an additional waiver extension from the DHS. For reference, we have been requesting our contract since 12/17/2024 and approximately every 2 weeks since.
How is this different?
Previously representatives told us our contract was auto amended, and we are in network and just waiting for our records to synchronize through all their systems. Now they are saying that an auto amended contract only means we do not have to complete an application and that the process is automatic. However, until they complete the contract we are technically not in network and the waiver is the only reason your visit should be covered. Once the waiver expires May 1st without a signed new contract, we will not be considered a Tricare provider at that time.
Other Concerns
When we started with Tricare in 2019 we accepted a rate that was 40% less than the commercial rates. While on the surface the rate might still seem reasonable, there is a lot that goes on behind the scenes that those fees pay for. At our rate with Tricare East clinicians could make more working at the local Bucees with no experience. It is common practice with insurance when you are new and unproven. We have spent 5 years proving ourselves with Tricare and working to show our value to their beneficiaries while working to improve our services. In the 5 years since we had started our compensation had not increased even though our expenses, just like all of you, had increased. In 2024, we began negotiations for a reasonable rate in earnest. Unfortunately, this process is very slow and the transition from East to West brought it to a standstill.
What does this have to do with Tricare West?
In the latest update this morning we were informed that, while our contract is in process, Tricare West uses their own rate contradicting previous reports stating they will honor the old rate until a new contract was signed. We were told that when our contract is finalized and sent to us, they will provide the rate they decided on and we must sign it to get paid for services we have rendered in 2025. While not said, it was implied that if we do not accept this rate, we cannot get paid.
Why is this a concern?
This creates a situation where we are agreeing to provide services without having any idea if we would be paid a reasonable rate. TriWest said they cannot provide any details and all we can do is wait. Furthermore, they stated that they will not expedite the process. During previous discussions with reps we were also told that large facilities are given priority suggesting our contract may not be processed until hospitals and large facilities are completed. Based on past experience this suggests our contract may not even be processed in 2025. More concerning news are reports from providers who have received a contract is a large portion have received a 25% rate cut. As we were already well below market, a further cut is not sustainable, and we would not be able to attain qualified talent at those rates. Some other reports contradict this. Overall, as the transition to TriWest has progressed the news has become more uncertain and concerning.
Is there anything you can do?
At this point we have no advice on how this can be fixed. We have spent over 40 hours on the phone with TriWest trying to find a resolution with no progress. More recent attempts have been met with they can do nothing, and we must wait. We have had several clients tell us that reps assure them we are in network and just waiting for claims to process and saying everything is fine. From our perspective, this is not the case. There are a minimum of 3 systems our records must be in, and we are only showing in the directory system and even that is incorrect. Claims have been stuck in processing since 02/03/2025 with no progress. More concerning is, while claims show in process, they now have a note that states we are not in network.
What about the mandatory deposit starting in May?
Unfortunately, with this new development we can no longer offer the deposit option in May. The deposit offered with the expectation that Tricare would eventually pay. The latest directive means there isn’t even a chance to get paid by Tricare.
Can I do cash pay starting in May?
We cannot compel you to choose to pay in cash. It is our understanding that if you opt to choose cash pay in May you cannot seek reimbursement for our services from TriWest. The reason is contracted providers must directly submit claims. We are stuck where we appear as a contracted provider so claims from you would be denied. Since our contract is not fully valid the claims would also be denied if submitted by us. In the end, it means using the cash pay option you would be opting to pay out of your own pocket. Verbal assurances from reps to the contrary are not valid as each time TriWest is contacted by us or clients conflicting information has been given. Claims processing follows what is documented and the documents would indicate no one can be reimbursed for visits starting May 1st.
We wish we could provide more details or words of assurance, but this would be misleading. At Ash Counseling we value honesty and transparency. We have always worked to provide you updates well in advance to allow you time to decide and adjust. We apologize that we were provided the latest news so close to the change.
From the latest updates we have been given you have the following options.
- Pause services and wait for TriWest to finish processing our status. Our best estimates based on experience are likely the fall of 2025 at the earliest but more likely closer to the beginning of 2026. This is only speculation as we do not have any insight into the process and how they prioritize things. This is also contingent on the fact that they offer a reasonable and sustainable rate.
- Try to find a provider that their credentialling and contracting has been finalized and executed with Tricare West. If you choose this option, we suggest starting your search as soon as possible as it seems options locally are limited. We do not personally know of any providers in the area that are accepting Tricare clients for young neurodivergent children, but we will be searching.
- Choose cash pay with the understanding the TriWest will most likely not reimburse your visits.
We encourage you to think of how you would like to proceed and let us know as soon as possible so we can help you as best we can.
