[HEALTH.MIL] Some Lab Fees Soon Will Be Billed To Tricare Patients

  • From: HEALTH.MIL@xxxxxxxxxxxxx
  • To: <HEALTH.MIL@xxxxxxxxxxxxx>
  • Date: Thu, 9 Jan 2014 12:12:00 -0600

Some lab fees soon will be billed to Tricare patients


By Tom Philpott 



Published: January 9, 2014

n/derivatives/landscape_804/2161831908.jpg> tricare_logo


Tricare beneficiaries soon will have to pay out of pocket for certain diagnostic
genetic tests that their civilian physicians order, but that the Defense Health
Agency doesn't view as appropriate or medically necessary.

In January 2013, without notice to beneficiaries or to health care providers,
Tricare stopped reimbursing clinical laboratories for more than 100 different
genetic or "molecular pathology" tests.

Beneficiaries haven't complained yet because the laboratories impacted are still
providing the tests that physicians order at no charge, said Julie Khani, vice
president of American Clinical Laboratory Association (ACLA), which lobbies on
behalf of the impacted laboratories.

To date, labs have provided about $10 million worth of free tests to Tricare
users.  "That's obviously unsustainable," Khani said.  Most of these tests cost
about $60 but a few carry charges of several thousand dollars.

Medical science has seen an explosion of clinical tests designed to diagnosis
and treat ailments based on a patient's DNA.  With thousands of new tests added
annually, driven by demand for personalized medicine, the Food and Drug
Administration is weighing the need to regulate the industry.

One of the more routine genetic tests that Tricare no longer covers is used to
determine if a woman who is pregnant carries a marker for cystic fibrosis, which
would increase chances of the baby having the disease.

If the woman has the marker, the father usually is tested too because both
parents must have the CF gene for the fetus to be at risk of CF. If both parents
are found to have it, the likelihood of their baby having CF is one in four,
according to the Cystic Fibrosis Foundation

With this test no longer covered, "Tricare beneficiaries will not receive the
standard of care or benefits equal to other insured patients," Khani said. The
American Congress of Obstetricians and Gynecologists has recommended prenatal
testing for CF for more than a decade, she said.

"It's covered by Medicaid and other commercial health plans.  It is also the
standard of care under VA-DoD clinical practice guidelines for management of
pregnancy," Khani said.  "Clearly an important test."

The Defense Health Agency disagrees.  Though no official was made available to
be interviewed, DHA gave written responses to our questions.  In one, it
dismissed the significance of the prenatal CF testing.

"Awareness that a fetus is at increased risk of having CF, in and of itself,
does not usually change the management of labor, delivery and the neonatal
period," wrote DHA officials.

Also, they noted, infants at birth are tested for a host of health conditions,
including CF, and those tests continue to be covered by Tricare.

In July, DHA did remove the CF test from its "no government pay" list but DHA
has continued to refuse to reimburse laboratories such tests.

Reps. Tom Marino and James P. McGovern, co-chairs of the Congressional Cystic
Fibrosis Caucus, urged Lt. Gen. Douglas J. Robb, director of DHA, in a letter
signed Monday to reconsider the decision not to cover prenatal CF testing,
arguing that "patient care will suffer."

What drove decision by Tricare last January to stop reimbursing for many genetic
or laboratory-developed tests (Lets) was the American Medical Association's
publication of new Current Procedural Terminology (CPT) codes for laboratory
tests.  The codes gave greater transparency to how Tricare was being billed, DHA
said. It could "identify specific laboratory developed tests that 1) have not
been approved or cleared by the Food and Drug Administration and/or 2) failed to
meet Tricare criteria for coverage."

For example, DHA said, "demand genetic testing that is not medically necessary
or does not assist in medical management of the patient" is not reimbursable.
Also, DHA emphasized that Tricare cannot cover any laboratory developed test
that has not been approved by the FDA.

The ACLA criticizes DHA on this point, arguing that Tricare does cover many
other laboratory-developed tests not FDA approved, including pap smears, a
routine test for cervical cancer.

The DHA "has a flawed interpretation of its own policy" which "places Tricare
out of step with other government and commercial payers, and it impacts the
patient," said Khani.  "We are deeply concerned that Tricare beneficiaries will
be denied vital services that are critical to the diagnosis and treatment of
disease.  And these are tests Tricare has covered historically."

If Tricare doesn't begin soon to pay for these tests, doctors won't stop
ordering them but laboratories will have no choice but to charge patients for
their cost, Khani said.

The Military Coalition, an umbrella group of military associations and veterans
groups, recognizes that laboratory profits and some very complex medical
questions are entwined in this debate between DHA and industry.

But one clear concern for beneficiary advocates, said Kathy Beasley, co-chair of
the coalition's health subcommittee, is that DHA has created two standards of
care regarding molecular pathology tests.  Patients who use civilian providers
will have to pay for these tests, while patients at military clinics and
hospitals won't.  Providers in the direct care system can continue to order such
tests knowing the military will pay for them.

 "Tricare beneficiaries without access to military treatment facilities are
relegated to second-class healthcare.  This is troubling," Beasley said.

DHA acknowledges this disparity in access to laboratory services between
purchased care and direct care.  Officials explained that a single contract is
in effect that allows Army, Navy and Air Force providers to request lab services
if military facilities cannot perform the tests in house.

"As this is not a DHA contract, we are in the process of gathering data
regarding the tests being ordered by MTF providers and will examine any changes
that need to be made to the contract," DHA said.  "Lab testing, whether ordered
in the private sector or by MTF providers, needs to be safe and effective."

But DHA said differences in lab test coverage might survive any such review
because purchased care has more restrictive laws and regulations.

Send comments to Military Update, P.O. Box 231111, Centreville, VA, 20120, email
milupdate@xxxxxxx or twitter: Tom Philpott @Military_Update



SOURCE:  Stars and Stripes article at




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