1.0 Purpose
This TRICARE pilot project will evaluate the
success of collaboration between Managed Care Support Contractors
(MCSCs), network EDs, and inpatient MTFs to offer the opportunity
to transfer clinically stable, qualified Uniformed Services beneficiaries
from civilian EDs to an inpatient MTF/eMSM for inpatient care and
treatment. The outcome of the pilot project would enable the Government
to consider operational and financial changes necessary to further
Military Health System (MHS) goals to optimize the capabilities
of the Direct Care (DC) system and support medical readiness, enhance
MTF/eMSM provider proficiency and graduate medical education programs,
responsibly steward taxpayer dollars, reduce beneficiary costs,
and enhance beneficiary satisfaction.
2.0 Eligibility
Policy
2.1 Participating Beneficiary:
2.1.1 Any Uniformed Services beneficiary
who shows as TRICARE eligible in Defense Enrollment Eligibility
Reporting System (DEERS) except for beneficiaries not eligible for
care in MTFs/eMSMs; and
2.1.2 Voluntarily elects transfer
to a local inpatient MTF/eMSM once stabilized in a civilian ED. Parents,
legal guardians, or authorized personal representatives may elect
transfers on behalf of others.
2.2 EXCEPTION: If clinically stable,
members on active duty greater than 30 days should be asked to agree
to transfer, but may be ordered to transfer depending on the circumstances.
3.0
Ambulance
Policy
3.1 A request by either a civilian ED or MTF/eMSM
shall, for purposes of this Pilot, constitute an “order” under TRICARE
Policy Manual (TPM),
Chapter 8, Section 1.1, to serve as authority
for TRICARE payment of a not-medically necessary transport to an
MTF.
3.2 If Medicare is primary payer and the claim
is denied by Medicare because the civilian facility has appropriate
facilities to treat the patient, TRICARE will cost share on the
claim. See TPM,
Chapter 8, Section 1.1.
3.3 If Medicare
is primary payer and the claim is denied by Medicare as not being
medically necessary, TRICARE will cost-share on the claim so long
as it is ordered by civilian or military personnel. See TRICARE
Reimbursement Manual (TRM),
Chapter 1, Section 14, paragraph 3.6.4.
4.0 Responsibilities
4.1 Participating
MTFs/eMSMs
4.1.1 Collaborate with regional contractor to identify
and educate civilian network facilities and their ED staff on the
goals and benefits of participating in this pilot project.
4.1.2 Determine
clinically appropriate MTF/eMSM capabilities and capacities to accept
clinically stable beneficiaries for transfer.
4.1.3 Provide
contractor and/or civilian EDs with information regarding MTF/eMSM
clinical capabilities, MTF/eMSM patient transfer hotline information,
MTF/eMSM patient transfer process, and beneficiary-focused educational
materials including a written beneficiary/personal representative acknowledgment
of cost-sharing and other financial obligations if they transfer
to an MTF/eMSM versus admitted to a civilian facility, to be given
to beneficiaries.
4.1.4 Staff a 24-hour patient transfer
hotline to receive requests for patient transfers.
4.1.5 Respond
to notifications of potential transfers from civilian EDs.
4.1.5.1 Confirm
eligibility and determine inpatient clinical capability and capacity
to accept the beneficiary for admission and treatment.
4.1.5.2 Provide
a verbal response within 30 minutes of the notification from the
civilian ED.
4.1.5.3 If MTF/eMSM
inpatient capability and capacity exists and both the attending
civilian physician and the accepting MTF/eMSM physician agree that
the beneficiary is clinically stable and can be safely transported
to the MTF/eMSM based on the medical status of the beneficiary and
the clinical appropriateness of the transfer, the MTF/eMSM shall
initiate a request to dispatch ambulance transportation within 30
minutes of the acceptance decision (when ambulance transport is
clinically required). Based on local procedures, the civilian ED
may request dispatch of the ambulance.
4.1.5.4 If no MTF/eMSM
capability exists or the attending and receiving providers do not
agree the beneficiary can be safely transported to the MTF/eMSM
based on the medical status of the beneficiary and the clinical
appropriateness of the transfer, the beneficiary remains the responsibility
of the civilian ED to arrange appropriate care in a civilian facility.
4.1.6 Collect
and report on project workload and financial data as required by
the Defense Health Agency (DHA) Project Manager.
4.2 Regional
Contractor (East and West Regions Only)
4.2.1 Collaborate with MTF/eMSM
pilot sites to identify and educate civilian network facility staff on
the goals and benefits of participating in this demonstration.
4.2.2 Establish
processes with or within civilian network facilities to:
4.2.2.1 Identify
eligible and stable Uniform Services beneficiaries seen in EDs that
require inpatient admission.
4.2.2.2 Inform
eligible beneficiaries of the opportunity to be admitted to a nearby
MTF/eMSM for further treatment as an inpatient.
4.2.2.3 Share MTF-provided
educational materials to the beneficiary, to include full disclosure
and patient/personal representative written acknowledgment of their
cost-sharing and other financial obligations related to both remaining
at their present facility and transferring to an MTF. All educational materials
will be coordinated with DHA Communications Office.
4.2.2.4 If the
beneficiary desires to participate in the pilot project, notify
the appropriate MTF.
4.2.2.4.1 If both
the attending civilian ED physician and the accepting MTF/eMSM physician determine
the beneficiary can be safely transported to the MTF/eMSM based
on the medical status of the beneficiary and the clinical appropriateness
of the transfer, the civilian ED shall prepare the beneficiary for
transfer to the MTF/eMSM and provide appropriate transfer clinical
and administrative medical documentation. Based on local procedures,
either the MTF/eMSM or the civilian ED may request dispatch of an
ambulance when clinically necessary.
4.2.2.4.2 If there
is no concurrence between the providers for safe transfer or the
MTF/eMSM declines the transfer, the beneficiary remains the responsibility
of the civilian ED to arrange appropriate care in a civilian setting.
5.0
Pilot
Project Service Areas
5.1 Army: Puget Sound eMSM - Madigan Army Medical
Center, Tacoma, WA and Naval Hospital Bremerton, WA; Womack Army
Medical Center, Fort Bragg, NC; San Antonio MHS e-MSM, San Antonio Military
Medical Center, Joint Base San Antonio, TX.
5.2 Navy: Naval
Hospital Jacksonville, FL; Tidewater eMSM - Naval Medical Center
Portsmouth, VA and 633rd Medical Group, Joint Base Langley-Eustis,
VA.
5.3 Air Force: 60th Medical Group, David Grant
Medical Center, Travis Air Force Base (AFB), CA; 99th Medical Group,
Mike O’Callaghan Federal Medical Center, Nellis AFB, NV; 88th Medical
Group, Wright-Patterson Medical Center, Wright-Patterson AFB, OH;
and 96th Medical Group, Eglin AFB, FL.
5.4 National Capital Region eMSM:
Walter Reed National Military Medical Center, Bethesda, MD.
6.0 Beneficiary
Cost Liability
6.1 Beneficiaries shall be responsible for all
required TRICARE cost-shares or MTF/eMSM fees.
6.2 See
paragraph 3.0 for
ambulance related cost-shares and the potential for denied Medicare claims.
7.0 Pilot
Cost Avoidance
7.1 Government and Contractor. Monetary cost avoidance
occurs as MTF/eMSM admissions eliminate the Government cost of inpatient
TRICARE claims (facility and professional fees). This is offset by
costs to the Government for ambulance transfers to the MTF/eMSM
and the marginal costs of MTF/eMSM inpatient admissions.
7.2 Beneficiary.
Eliminates beneficiary cost-sharing of an inpatient TRICARE claim
but adds potential for cost-shares or denied claims relating to
ambulance transfers. See the TPM,
Chapter 8, Section 1.1 and the TRM,
Chapter 4, Section 4.
9.0 Effective
And Termination Dates
This pilot project
is effective for elective patient transfer requests from civilian
EDs to designated inpatient MTFs/eMSMs as of July 25, 2016. The
pilot project shall terminate on the last day of a Region’s current
contract, or two years from the start of the pilot project, whichever
comes first.