A technology flub within the TRICARE West region has put immense distress on autism therapy providers who care for military families.
As far back as mid-December, several sources have told Autism Business News that nearly all health care providers are unable to use the platforms that TRICARE West region contractor, TriWest Healthcare Alliance, provides to check member eligibility, submit or check prior authorizations, or process claims.
This means providers are going weeks without getting paid for services provided to TRICARE members. As a result, several autism therapy providers are closing or limiting services to TRICARE beneficiaries.
In 2022, the Defense Health Agency (DHA), a division of the U.S. Department of Defense, awarded the $65.1 billion contract to administer TRICARE benefits to Phoenix, Arizona-based TriWest Healthcare Alliance. The transition ramped up in the latter part of 2024 with TriWest Healthcare Alliance taking the helm at the start of 2025.
“Of course they told everybody it’s going to be seamless — no problem — everything’s going to port into the new system,” Jodi Rumph, owner of Family Strategies, told ABN. “The new system doesn’t work.”
Several autism therapy and other outpatient providers told Autism Business News that they were assured by TRICARE communications and representations from TriWest Healthcare Alliance that the switch away from the previous contractor, Health Net Federal Services, would require little to no work on their part.
Other health care providers have experienced similar challenges, and awareness of the issues have grown.
As the complaints mounted, DHA stepped in to give sweeping approvals for certain services, exempting most providers from prior authorization. Autism therapy was not included. The waiver, announced Jan. 25, also did not include patient care, laboratory-developed tests and extended care health option services.
“TriWest’s referrals portal has experienced issues that have affected the processing of new referrals,” Jacob Sanchez, referral management subject matter expert at the DHA, said in a press release. “If you have TRICARE Prime and are in the West region, this waiver will allow you to access specialty services without interruption to your care.”
The waiver is retroactive to the beginning of the year and runs to the end of March.
The exemption from the waiver means that autism therapy providers can expect no relief if their revenue is reliant on TRICARE. Providers that are in communities with military bases or otherwise large military family populations are the hardest hit — based on the relative proportion of the client base that are TRICARE beneficiaries.
The issue is also on the radar of at least some federal lawmakers. On Jan. 17, Washington state Congresswoman Marilyn Strickland sent a letter to DHA, which she released to the public on Jan. 23, demanding action and clarity on the situation and a potential resolution.
“Ultimately, TriWest’s lack of preparedness and the Defense Health Agency’s lack of contract oversight are actively harming military readiness and the lives of our servicemembers, families, and retirees,” the letter states. “We cannot allow servicemembers and their families to lose health coverage through no fault of their own.”
Several sources have described peer organizations shuttering. Leaders at some of these organizations have also decided to stop taking TRICARE-covered patients and put a pause on service for existing patients in the program.
One autism therapy clinic owner in Texas, who hasn’t been paid since Jan. 2, has about $200,000 in outstanding claims. This provider spoke to ABN on conditions of confidentiality because they fear reprisals for sharing their experience. They intend to progressively reduce available office hours, reassessing at the beginning of each month. The company is also considering taking on additional debt.
“If we’re not being reimbursed, we wouldn’t even have funds to pay the loan back,” that clinic owner told ABN. “We’re small business owners; we’re not part of a major corporation or owned by a private equity firm.”
Providers of this size rarely hold large cash reserves, leaving many relying heavily on a steady, uninterrupted flow of claims revenue. Even larger providers or those with less TRICARE represented in their patient bases and cash flow are smarting from the lack of payment.
Markets with a large military population often have significant overrepresentation of TRICARE beneficiaries relative to other communities. Small health care providers that operate in these communities may face overexposure to the struggles of a payer, such as TRICARE, that may spill out and impact provider networks.
As of the time of the interview, the autism therapy provider told ABN there was no clear timeline to resolution provided by TriWest Healthcare Alliance or TRICARE.
Several sources describe unhelpful webinars hosted by TriWest, hours on the phone seeking answers and attempting to manually do certain business processes, and a dearth of direction from any entity.
Mary Shabunia, operations director for Trevor’s Place, an all-in-one ABA, speech and occupational therapy provider, told ABN that the TriWest credentialing system is also down, meaning that the company can’t add the providers they want to hire from closing operations to the TriWest system.
“We want to help the other clinics if they have to make the decision to close. We want to be able to bring those clients over so there is no gap in coverage. We want to be able to offer employment to those employees,” Shabunia said. “But the credentialing process is another process that’s totally broken.”
Shabunia and the autism therapy clinic owner independently noted that many impacted autism therapy providers operate where they do and serve who they do out of a combination of two desires: to build business in the communities they love and support the American fighting force.
“I just pray that there is somebody out there that can help us because the military families do not deserve this,” Shabunia added.
In response to ABN’s questions, TriWest Healthcare Alliance emailed a pitch for providers to join its provider network. TriWest Healthcare Alliance did not comment on any of the problems that providers have discussed.
“We are grateful to the providers who have joined our network as we work together to care for our nation’s heroes,” the email states.
DHA’s awarding of contracts in 2022 represented fundamentally different arrangements than were offered in previous bidding-award cycles, necessitating changes across all of TRICARE. Some autism therapy providers in the TRICARE East region have told ABN about system hiccups. The East region contract is administered by Louisville, Kentucky-based Humana Inc. (NYSE: HUM) and its government subsidiary.
“So, although we were affected for a few weeks, we are now seeing payments again,” one multi-state autism therapy provider executive told ABN after the company found a system workaround.
This isn’t the first time that TriWest Healthcare Alliance has faced scrutiny.
The company is in active litigation with the technology company BizFlow Corp, which TriWest Care Alliance selected as a technology subcontractor and included in its bid for the TRICARE West contract.
In a complaint filed in the U.S. District Court for the Eastern District of Virginia, BizFlow alleges that TriWest is in breach of its contract, has misappropriated BizFlow’s trade secrets and conspired with another company that BizFlow said it hasn’t yet identified.
BizFlow asked in its complaint, among other things, that the courts enjoin TriWest Healthcare Alliance from using or further exploiting allegedly stolen proprietary information. It also requests the court order TriWest to pay BizFlow for the costs of participating in the contract bidding process, the value of its technology, the funding dedicated to BizFlow in the contract and other damages.
BizFlow alleged that TriWest Healthcare Alliance selected it to provide several technology platforms that are not working for providers in the TRICARE West region. The contracted service includes a beneficiary mobile app, DHA self-service employee portal, a beneficiary self-service portal, an automated provider business process management system, a claims and related information system, an interactive process tracker for TriWest and other users, and a secure potential-quality-issue submission tool.
DHA announced on Jan. 21 that TRICARE members have an extended deadline to set up their payments with TriWest Healthcare Alliance given struggles with those systems as well.
Despite the suit and request for injunctive relief, it’s not clear how this legal dispute may factor into the present situation providers face.
TriWest Healthcare Alliance didn’t answer specific questions about this suit. Attorneys for BizFlow acknowledged ABN’s request for comment but did not respond to questions as of the writing of this article.
The Virginia district court ordered the suit be moved to the federal court in Arizona on TriWest Healthcare Alliance’s motion. TriWest has asked the Arizona district court to stay the case and send the dispute to arbitration. The judge over that case has not ruled on that motion as of the writing of this article.
TriWest Healthcare Alliance has already prevailed in federal court to get this point. The previous contractor, Health Net Federal Services, challenged the procurement process, eventually elevating the dispute to the courts. In February 2024, a judge sided with the federal government and TriWest.
The company has also had entanglement with the U.S. Department of Justice. In 2021, TriWest Healthcare Alliance agreed to pay $10 million to settle False Claims Act qui tam, or whistleblower, allegations. In part, TriWest was accused of inappropriately retaining negotiated discounts with service providers.
In December 2020, the DOJ announced it reached a settlement with the company regarding alleged retained overpayments from the VA Patient-Centered Community Care Program (PC3) and the VA’s former Veterans Choice Program (Choice). TriWest agreed to pay $179 million.