It’s Giving ‘Tricare Prime Problems’
Dealing with TRICARE’s clawbacks feels like being Erika Jayne on RHOBH—one moment you think the finances are settled, and the next, someone’s coming after you for millions. TRICARE doesn’t just take back a little; they take it ALL, leaving you scrambling to figure out what just happened.
I couldn’t help but wonder: is dealing with TRICARE’s billing system the healthcare version of being cast on Real Housewives?
One minute, everything’s glitz and glam—claims are approved, money is flowing, and life feels good. But just when you start to relax, TRICARE pulls an Erika Jayne-style plot twist. Suddenly, those payouts are “mistakes,” and they’re clawing back every dollar faster than a Housewife dodging accountability at a reunion.
When I first started working in mental health billing, I was both overwhelmed and intrigued. TRICARE’s system was like a complicated puzzle, and I was determined to figure it out. What I quickly learned is that while TRICARE operates like a well-oiled machine, it can also feel impersonal and rigid. They mean what they say—even when they’re wrong—and working with them requires persistence, strategy, and a deep understanding of their rules.
One of my earliest challenges involved a clawback that took my breath away: 130 claims, totaling up-to $14,000, for active service members. TRICARE had approved and paid out these claims in full, only to later declare that they’d made a mistake. The amount had to be returned—by the practice. Asking military families to cover these costs was out of the question. Many of these families already face significant challenges, and the thought of adding a financial burden to their plates felt wrong on every level.
Instead of giving in to frustration, I rolled up my sleeves. I worked tirelessly to backdate referrals, resubmit claims, and navigate TRICARE’s rigid processes. The work was painstaking, requiring hours of follow-up and meticulous documentation, but it was worth it. About 60% of the clawbacks were resolved, saving the practice thousands of dollars and ensuring that service members and their families weren’t left to bear the financial fallout.
What I realized during this process is that working with TRICARE is not about fighting the system—it’s about understanding it and finding ways to make it work for you. Yes, the rules are strict, and the processes can be frustrating, but they exist for a reason. By aligning with these rules and staying persistent, you can advocate for military families and help them access the care they deserve.
Every day, providers who work with TRICARE face tough decisions. The system can feel impersonal, and the work is often thankless. But when you see the impact—when a service member gets the mental health support they need or a family finds relief knowing they’re cared for—it becomes clear why the effort matters.
Top Tips for Providers Navigating TRICARE
Streamline Your Workflow:
Use billing software that flags missing or incorrect fields before submission.
Verify Tricare Policy- (Select, Prime, ect) Pro-tip- Tricare Prime Requires Referral/Auths to Out-of-network-Certified providers.
Schedule weekly claim audits to catch errors early.
Documentation is Key
Meticulous documentation is your strongest defense against clawbacks.
Always Confirm patient eligibility and network status upfront.
Keep detailed records of referrals and authorizations.
Log every communication with TRICARE, including dates, names, ticket numbers and call summaries.
Build a Claims Submission Checklist
Avoid unnecessary denials with a clear, repeatable process:
Verify all patient information is accurate.
Ensure CPT and ICD-10 codes match the treatment provided.
Double-check referral and authorization numbers - attach to claim -PRIOR to submission.
Consistency is Key: Communicating with TRICARE Members
TRICARE often provides incorrect or inconsistent information to members, which leads to confusion. This is why sticking to the script matters when communicating in your office.
TRICARE is the uniformed services healthcare program for active duty service members, active duty family members, National Guard and Reserve members and their family members, retirees and retiree family members, survivors, and certain former spouses worldwide.
Extensive Reach: TRICARE covers active-duty service members, retirees, and their families in over 200 countries worldwide.
Multiple Plans: TRICARE offers a variety of plans, including TRICARE Prime, TRICARE Select, and TRICARE For Life, each with its own set of rules and requirements.
Claim Denials: Incorrect coding and insufficient documentation are leading causes of TRICARE claim denials.
Clawback Timelines: Clawbacks can occur up to three years after claims are approved and paid.
Appeals Process: Providers often need to submit multiple levels of appeals to resolve denied or clawed-back claims, with a resolution time averaging 30–60 days.
Getting a resolution often requires an experienced and dedicated biller who knows how to navigate the provider portal, provider support channels, and the complexities of TRICARE’s processes
Authorization Challenges: What You Need to Know
40% of authorization requests require additional follow-up or documentation before approval.
One common reason? Members requesting referrals through the wrong channels.
Key Reminder: Referrals and authorizations must come from a PCM (Primary Care Manager) and must be specifically requested for the provider the member intends to see. If the request isn’t directed properly, delays and denials are almost guaranteed.
Consistency and clarity in the referral process help avoid unnecessary back-and-forth.
Provider Shortage & TRICARE Access
Nationwide, only 68% of providers accept TRICARE, limiting care options for military families. However, in Hampton Roads, a significant number of providers remain out-of-network but TRICARE-certified, meaning they can still offer care—with the right referrals and authorizations. Understanding these distinctions is key to ensuring access to the services military families need.
Turnaround Times: TRICARE’s claim processing can take 14–30 days on average, with delays often pushing beyond 60 days.
Specialty Coverage: TRICARE includes unique benefits like behavioral health services, physical therapy, and maternity care, but requires strict compliance with documentation for reimbursement.
Working with TRICARE often feels like an uphill battle for healthcare providers. While the mission to serve military families is commendable, the reality of navigating TRICARE’s system can leave providers frustrated and questioning whether they can continue to participate. The process is riddled with complexities, delays, and financial strain—all of which impact providers and the families they serve.
