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Latest News

New Tricare Breastfeeding Benefits Lead to Reimbursement Fiascos

Breastfeeding 001

 

Earlier this year, the Defense Health Agency (DHA) tweaked Tricare coverage for breastfeeding supplies and added a new benefit: coverage of human milk from milk banks to feed premature or sick babies in cases where supplementary feeding is necessary.

The assistance has been welcomed by new moms and breastfeeding advocates, but the rollouts have not been without snags. The new policies have forced Tricare beneficiaries, supply companies, milk banks and defense health program contractors to navigate through uncharted territory, with some beneficiaries forced to buy supplies themselves or shell out thousands and seek reimbursement.

The Pentagon changed its policies on providing breast pumps to beneficiaries in March, cutting coverage for deluxe models and their associated supplies and placing limits on pump kits and other necessities. The changes were in response to a 2018 Defense Department Inspector General report that found the DHA overpaid for breast pumps and supplies by $16.2 million.

The DHA also announced in March that Tricare, the military health program, would begin covering the cost of human milk for babies who need it and whose mothers may be unable to provide an adequate supply.

But the milk bank benefit was introduced before a formal policy had been drafted for Tricare's contract management companies to follow, leaving some moms to sort out the problem on their own.

And moms who had ordered supplies and breast pumps before the policy change also found themselves caught between suppliers and the DHA's slow reimbursement process.

In July, military beneficiaries who had ordered a breast pump through Pumping Essentials, a Moraga, California-based company, received a letter saying all current and future orders for breast milk storage bags from Tricare beneficiaries were canceled.

The reason, according to the letter, was that Tricare contractors Humana Military and HealthNet Federal Services weren't paying the bills.

"[The contractors] have drastically mismanaged the handling of these claims, resulting in significant amounts of unpaid claims to Pumping Essentials and many other providers. ... At this time, the volume of unpaid claims has put our company in a position where we can no longer sustain the debt that is accruing," company officials wrote.

The letter sent many beneficiaries scrambling for a new supplier.

"I was planning on calling soon to ask how to get a resupply, so obviously [I'll] be finding a new place to call for my breast milk storage bag needs," wrote one military spouse to Military.com.

A DHA spokesman said the problem stemmed from the Inspector General audit, which uncovered the overpayments, leading its Tricare contractors to overhaul their claims processing systems.

Due to the system changes, Humana Military and HealthNet Federal Services were forced to "manually process these claims," said to DHA spokesman Kevin Dwyer. The changes are expected to be complete by early August.

According to the DHA, as of July 24, there were 5,244 pending claims for Pumping Essentials, with a total billed amount of $1,016,611.

Pumping Essentials executives did not respond to a request for comment. But an employee who answered the phone said the company is still trying to resolve the situation with DHA and hopes to eventually do business again with military beneficiaries.

She said the amount owed to the company became a large burden that threatened Pumping Essentials' financial stability and, regrettably, they had to stop doing business with the Pentagon until the issue is resolved.

More than 83,000 Tricare beneficiaries have utilized the program's breast pump and supply benefit since Jan. 1, 2018, according to the DHA.

Likewise, milk banks across the country have had to navigate through a payment and reimbursement system that wasn't solidified before the milk bank benefit was announced.

Nearly as soon the benefit was introduced, Mothers' Milk Bank in San Jose, California, was "flooded with calls," according to lactation specialist Pauline Sakamoto. But there were few to no guidelines for milk banks to follow.

"There continue to be questions as to what the benefit is and what the families are responsible for paying," Sakamoto said. "For example, shipping costs. Is that part of Tricare coverage or not? And to some extent, Tricare has a co-pay, but we aren't seeing that families are getting requests. There are a lot of issues right now swarming around this coverage."

Earlier this year, Kaitlynn Cornelius, wife of Navy Aerographer's Mate 2nd Class Philip Cornelius, gave birth to twins at 28 weeks into the pregnancy. The birth was physically traumatic for Kaitlynn, leaving her unable to produce enough milk for what was expected to be a lengthy hospital stay until the babies' projected due date. Neither infant could tolerate formula and, without supplemental breast milk, they were failing to thrive.

Having learned about Tricare's new breast milk bank benefit on a Facebook page, Kaitlynn pursued it. The babies got the needed nutrition, she said, but tapping into the benefit, understanding the cost and managing the reimbursement process was anything but easy, leaving the couple with more than $10,000 in debt.

"They didn't have a procedure in place," she said of the Defense Health Agency. "I feel like Tricare didn't provide any instruction to its contractors. There just wasn't clear communication."

The issue was eventually resolved but, for a while, the Corneliuses relied on support from the Navy-Marine Corps Relief Society, the hospital and the supplying milk bank.

A persistent employee at Humana, the contractor for the Tricare East Region, and not direct assistance from DHA, "got us all the answers."

"She figured out the preauthorization numbers and procedure codes, resubmitted all the claims, got all the information," Kaitlynn said. "She got those checks coming through."

Lindsay Groff, executive director of the Human Milk Banking Association of North America, said such "hiccups" for the new benefit were not unexpected.

"We are thrilled that the benefit came through ... and we were also of the understanding that when things get passed, it can be a little tangled in the beginning. We did anticipate there would be some headaches, and indeed there have been," she said.

DHA officials said that most contractors are not having issues paying claims if beneficiaries submit their claims properly. "However, some contractors are having difficulties providing the right documentation for their claims," Dwyer said. "In these instances, contractors are working with providers to review the benefit so corrections can be made and claims are paid."

As of July, seven beneficiaries had filed claims for banked donor milk and five claims were pending, the DHA said.

According to the DHA, all claims must be submitted by either the provider or the beneficiary. They must include the prescription and an itemized invoice, with the beginning and ending dates for the milk purchased, and must be submitted listing the infant as the patient.

Banked donor milk is covered for babies less than a year old and must be approved with a referral or prescription on file. A new referral or prescription must be submitted every 30 days.

Sakamoto said she looks forward to reading the final policy and contract, which she said will help all parties involved.

"It is surprising that it was not clear-cut as to what the benefit is. Clearly, the message has been, 'Stay with us, we are going to get through it,'" she said.

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