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.