Question and Verify: TRICARE Authorized Civilian Mental Health Facility Referrals

Managed Care Support Contractor by TRICARE Region - East - Humana Military - tricare-east.com - 800-444-5445 - West - Health Net - tricare-west.com - 877-988-WEST (877-988-9378) - Overseas - International SOS - tricare-overseas.com - Country-Specific - Toll-free Numbers
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By Krystyna Bienia, Psy.D. and Amy Serda, MSN, RN-BC
October 28, 2019

You’ve determined your patient requires a referral to a specialized mental health in-patient or residential care facility to participate in an intensive treatment program with 24-7 structured support and medical oversight. But knowing where and how to refer your patient for an increased level of care can pose a challenge, especially if your military treatment facility (MTF) is not located near a major treatment center that offers inpatient or residential mental health services. Where do you turn to find a facility that offers the level of care needed for the type of issue your patient is struggling with? And how do you know if the costs will be covered?

Let’s start with a caution: Did you know that civilian mental health facilities are marketing directly to MTFs with the promise of specialized focused treatment programs and offers of incentives such as free travel? This can lead MTF providers to unintentionally refer and transport beneficiaries to facilities that are not TRICARE authorized and for which TRICARE is not allowed to reimburse care. This, in turn, can lead to beneficiaries learning the shocking news that they’re responsible, out-of-pocket, for the entire cost of the duration of their care! Unlike their civilian counterparts who, barring an emergency, know they must obtain prior authorization from their insurance company to be admitted with coverage to a hospital or treatment facility, our beneficiaries may be more acculturated – and vulnerable – to assuming their care needs are covered under their TRICARE universal coverage.  

Business is business. In the civilian for-profit world of mental health programs and facilities, the fully insured military population may be seen as “low hanging fruit” for facility start-ups and business development (e.g., community needs assessment), recruitment of clients, and targeted marketing. The tricky part is these marketing and recruitment efforts are the norm for many mental health facilities, which may or may not be TRICARE certified. Non-TRICARE certified means that TRICARE currently has no utilization or quality or evaluation oversight authority, and will not cover the cost of treatment at this facility. Most importantly, since treatment outcomes and program effectiveness are unknown for non-TRICARE certified facilities, this potentially exposes service members to care that is not – or not yet – verified to be effective or safe.

So how can MTFs help protect providers and beneficiaries from financial or other potential harmful consequences from non-authorized referrals?

Follow these recommendations and safeguards:

  • Coordinate all care with, and obtain authorization from, the appropriate Managed Care Support Contractors (MCSCs) BEFORE sending the patient for care. Remember, service members require referrals for all levels of mental health care.
    • Each TRICARE region has its own MCSC who is responsible for administering the TRICARE program in that region. Contact information can be found on the Military Health System website.
    • MSCSs are not required to send a beneficiary to the facility identified on the referral.
    • Generally, all referrals are processed within three business days.
    • MCSCs will select, with consideration of the MTF recommendation, an appropriate, qualified TRICARE-authorized provider for the referred level and scope of care.
    • If medical necessity has determined that treatment must be provided at a non-TRICARE-authorized facility or program, MCSCs must receive a Supplemental Health Care Program (SHCP) waiver approved by DHA prior to approving and reimbursing any care.
  • Recognize the red flags of making potentially untoward or incentivized referrals.
    • Accepting “free” flights/travel or other incentives for service members is generally prohibited because of gift rules and it could be seen as a “kickback” to encourage referrals to be sent to a particular facility.
    • If in doubt, call the MCSC. Individual cases can be reviewed by MCSCs to determine if the circumstances would support acceptance of an offer or incentive.
  • Know and adhere to the rules for determining when care is urgent or emergent. These types of care are not considered emergent or urgent and always require preauthorization:
    • Psychiatric residential treatment center care for children and adolescents
    • Inpatient or residential substance use disorder treatment facilities
    • PTSD and eating disorder programs

TRICARE is committed to helping MTFs provide the effective, high quality care their patients deserve. MTF providers can help prevent financial and emotional harm to their patients by not directing care to civilian mental health facilities, and not directing care as urgent in cases where treatment is not considered urgent, without first coordinating with and receiving authorization from an MCSC.

Dr. Bienia is a clinical psychologist serving as a senior policy analyst and Autism Care Demonstration clinical program manager for the Defense Health Agency in the Medical Affairs Directorate. She holds a doctorate in clinical psychology.

Ms. Serda is a registered nurse serving as a behavioral health nurse consultant and Autism Care Demonstration program manager for the TRICARE Health Plan Division of the Defense Health Agency. She maintains her board certification in psychiatric-mental health nursing, holds a bachelor’s and master’s degree in nursing, and is currently working on her Doctorate in Nursing Practice. 


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • It would be helpful if you could utilize the provider/facility directory on the website to search for behavioral health/substance use services. The option is available, but yields zero results for all behavioral health services. I've always been told to call to receive the most updated listing, but typically receive a list of services that may not be appropriate for the patient needs. It would be easier if the option was available through the website. Thank you!

    • Thank you for the response and feedback. We will route your message to the department that oversees the directory.

      -- Amy Serda

       

  • Tricare isn't the biggest blocking point in mental health. If someone has a psychosis and becomes violent or a danger to themselves and get involentarly committed they can be let out after just days or a week. But then because Tricare requires a referral from PMC for care there will be a 2-3 month gap before the person can even try to make a follow-up appointment and will be a danger to themselves or others the entire time. This can wreck lives by just not allowing for a referral because PMCs are so over run and can't make an appointment for so long. This is where military medical systems fail. Why Tricare prime, while seaming good, results in extra hospitalizations and poor care. They are the road block for proper mental health care. Not sure if that makes sense but have seen how poorly the system plays out resulting in suicides or violent crimes that wreck families because they were waiting for a referral so they could get the proper care.

    • In September 2016, DHA removed the requirement for a referral for outpatient office-based mental health and substance use disorder services to network providers for Prime beneficiaries. Please note that a referral, and sometimes an authorization, is required for other levels of care. Additionally, all active duty service members are required to obtain a referral and authorization for any care requested to be rendered in the purchased care system. We recommend beneficiaries connect with their regional contractor to locate providers. Also a regional contractor case manager may be assigned to help coordinate medically necessary care.

      -- Dr. Bienia and Ms. Serda

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