tricare prime fraud waste and abuse

[basshawg95]

I am retired Navy, on Tricare Prime. I am currently on a CPAP machine for sleep apnea.
When i first recieved my CPAP, I was contacted by a company, we will call Lcare, for legal purposes, for my CPAP supplies.
I have been getting phone calls monthly, asking if i need supplies. While i don't need them monthly, i needed some supplies recently, and ordered them thru this company. It took a while, but i finally received my order, along with a statement of what was billed to Tricare and what I have to pay.
After looking over this statement, i felt that the prices this company was charging tricare for these supplies was a little high. I did some online pricing for the same items and discovered that this company is making around a 400% profit from these supplies.
Being the concerned taxpayer and military retiree that I am, i went to the Tricare North website to lodge a complaint. Which i did.
After waiting a week, with no response, I called the hotline number and spoke to a representative there.
She told me that when a company wins a government contract, the prices it charges are in the contract, so there's nothing that can be done about price gouging.
Does anyone know if this is a true statement? If so, is there any other avanue I can use to report suspected fraud, waste and abuse in the Tricare system?
Will it do any good?

 

[GW8345]

Tricare does not have to pay what the company bills, there is a set rate and Tircare will pay that amount. I see it also in my statements also, a company will bill Tricare a certain amount and Tricare will pay an amount that is "Tircare Approved", the rest is dropped. This is why a company will try to over bill Tricare but Tricare doesn't fall for it. If you feel the company is overbilling Tricare, you can use another company that accepts Tircare Prime that has lower prices. Never heard of a company getting a contract through Tricare prime, usually they accept Tricare Prime and they know they will receive a certain amount for services billed, to my knowledge, there is not contract involved.

 

[BernieP]

First, good on you for doing the research and reporting it.

I have no idea what the contract allows, I would imagine that whether it's Tricare or BC/BS, the vendor or vendors, cannot charge more than their contract allows.
You would think that Tricare would have negotiated a price a tad lower than retail.
Then again, this is the government we are talking about and there are rules....

 

[czygvtwkr]

Liberty medical kept sending my grandfather diabetic testing machines and he wasn't even a diabetic. When he died and we cleaned out his house we found a dozen of them in the box.

 

[oldman]

I've been on Medicare and Tricare for Life some years now. Medicare pays some, usually less then Tricare, then Tricare pays some more. From the summaries I get from Tricare that contains how much was billed, how much each of them paid never has the billed price been met. I can only think of one time I was asked to pay $14 that wasn't covered. Proves to me that the billing prices are always inflated.

 

[vince77]

find a hobby

 

[BernieP]

Tricare does not have to pay what the company bills, there is a set rate and Tircare will pay that amount. I see it also in my statements also, a company will bill Tricare a certain amount and Tricare will pay an amount that is "Tircare Approved", the rest is dropped. This is why a company will try to over bill Tricare but Tricare doesn't fall for it. If you feel the company is overbilling Tricare, you can use another company that accepts Tircare Prime that has lower prices. Never heard of a company getting a contract through Tricare prime, usually they accept Tricare Prime and they know they will receive a certain amount for services billed, to my knowledge, there is not contract involved.

good point, it's not uncommon for doctors and I'm sure equipment providers to bill an amount higher than what the plan "allows".
One doctor explained that it went to the way BC/BS determined the going rate - yes, it's some statistical bull sheet, so they bill higher so as to drive the median up.
They still only get reimbursed what the plan allows and most times they are only allowed to bill the insured for a specified amount.

Maybe I misunderstood OP, I thought they said the vendor was getting reimbursed by Tricare at a rate higher than the going market.

 

[officeguy]

When comparing prices for cpap supplies, make sure you compare apples/apples. Many of the items sold through ebay or amazon are cheap chinese knock-offs of the respective brand products. If they work for you, great, but you have to be aware that it is rarely the same product.

The reason suppliers to tricare and medicare bill large numbers is because the goverment requires them to do it that way. The reimbursement they receive is indeed fixed, regardless of the number on the bil.

 

[BernieP]

When comparing prices for cpap supplies, make sure you compare apples/apples. Many of the items sold through ebay or amazon are cheap chinese knock-offs of the respective brand products. If they work for you, great, but you have to be aware that it is rarely the same product.

The reason suppliers to tricare and medicare bill large numbers is because the goverment requires them to do it that way. The reimbursement they receive is indeed fixed, regardless of the number on the bil.

another good point.

If anyone saw a recent story - think it was 20/20 - on these knock off products sold on line and at discount store (i.e. Dollar stores)
Some can contain hazardous material, so it goes from ineffective to dangerous.
What was it, Viagra, sold online contained paint and some other compoounds that were never intended for human consumption.

 

[MarieB]

I know someone in a medical supply industry. She told me that the VA pays much more for some equipment than any hospital would and that they are basically being raped.

Not sure about this particular case, but it wouldn't surprise me if the "allowed amount" is too high to begin with based upon what I've heard.