Texas TriWest investigation targets disputed TRICARE claim denials
Texas Attorney General Ken Paxton is examining whether TriWest’s handling of disputed TRICARE denials violated consumer law.
By Tom Brennan · Health & Medicine Correspondent
3 min read
Texas Attorney General Ken Paxton opened the Texas TriWest investigation on Sept. 1 over reports of TRICARE medical claims being denied after beneficiaries were incorrectly listed as having other health insurance. The inquiry matters to military families and veterans because it will examine whether the contractor’s claims practices violated Texas consumer-protection law.
Paxton’s office said it issued Civil Investigative Demands to TriWest Healthcare Alliance and plans to interview consumers and company employees. The stated aim is to determine whether the company violated the Texas Deceptive Trade Practices Act; the announcement did not allege a proven violation, announce a lawsuit or impose a penalty.
Why is Texas investigating TriWest?
The attorney general’s office said complaints alleged that TriWest incorrectly recorded beneficiaries as having other health insurance, known as OHI, and that the records led to denials of numerous health-care claims. The office said the investigation also follows reports and an admission concerning wrongful denials.
TriWest is a private government contractor that serves as the Defense Health Agency’s support contractor for the TRICARE West Region, according to the attorney general’s office. The office also said TriWest manages the Department of Veterans Affairs Community Care Network. TRICARE is the military health program for active-duty service members, retirees and their families, NBC News reported.
What does other health insurance mean under TRICARE?
Official TRICARE guidance defines OHI as health coverage a beneficiary has in addition to a TRICARE plan, such as coverage through an employer, a spouse’s employer or a private insurer. In most cases, TRICARE pays after that other insurance has processed a claim, the guidance says. A denial may therefore be proper when a claim reaches TRICARE before actual OHI has processed it.
Texas is examining a different question: whether TriWest’s records incorrectly showed beneficiaries had OHI in the first place. Beneficiaries can report OHI changes to their regional TRICARE contractor by phone, online questionnaire, mail or fax, according to TRICARE guidance.
A Texas patient’s case
The attorney general’s office cited the case of Guy Shoemaker, whom NBC News identified as a Fort Worth resident and retired Army sergeant first class. The office said TriWest treated his vision plan as OHI while he was receiving cancer care, resulting in denials of claims for treatment and appointments.
Shoemaker tried to correct the issue for almost two years and received relief after NBC aired a report, according to the attorney general’s release. That account is an example cited by the state, not a finding of liability against TriWest.
TriWest told Becker’s it was reviewing the Civil Investigative Demand and said it was committed to helping military families across Texas. Becker’s also reported that TriWest Chief Executive David McIntyre Jr. previously acknowledged that some claims had incorrectly reflected OHI, producing initial denials, delays and frustration, and said the company was working to address the issue.
This story draws on original reporting from NBC News.