This is an exclusive BHB+ story

Autism therapy providers have been pounded across the nation by foul-ups that spoiled the transition of the TRICARE regional contracts at the beginning of the year.

Early in the year, complaints about the vendor that administers the western region contract for TRICARE, TriWest Healthcare Alliance, surfaced across several segments of public discourse. At the time, Autism Business News found that nearly every system providers needed to use for administrative work with TriWest was nonfunctional.

At nearly the same time, providers who engaged with the eastern TRICARE contractor, Humana Military, began to disclose similar problems.

For months at a time, technology systems did not work as promised, and payments were not made, driving an existential crisis for the providers that often either go out of their way to serve active military members and their families or are based in communities around military bases and installations.

This has left several autism therapy providers — although the problems with TriWest Healthcare Alliance and Humana Military were not limited to autism therapy providers — feeling helpless, frustrated and worried about their organization’s survival and access to care for military families. Autism Business News has spoken to several autism therapy and related providers on condition of anonymity for fear of reprisals from sharing their experiences.

“It was clear when it went live — and we heard this from all the other groups we know — nothing was ready to go on Jan. 1,” said the clinical director of one Tennessee-based practice.

Fortunately, by mid-March, many of the most critical issues had been resolved by Humana Military and its subcontracted claims processor PGBA, according to several sources. One source posited the situation was about “85% resolved” during an interview.

Providers in several states have told ABN that payments for claims are coming through. Claims processes appear to be working; authorizations are being accepted and assessed. Others say that claims are being paid and processed within a typical 30-day timetable but are not going at an even cadence. Others still complain that the self-service tools are not correctly displaying provider information or allowing providers to track their claims and payments.

Still, in stark contrast to reporting done earlier in the year on the TriWest Healthcare Alliance process, several providers have said that PGBA and Humana Military are communicating with providers to some degree and making demonstrable progress. What’s more, the federal apparatus over TRICARE has taken greater notice as the contract transition crisis has carried on. TRICARE is part of the Defense Health Agency (DHA), a division of the U.S. Department of Defense.

“I received a call last week from a DHA rep working with Humana Military apologizing for the entire fiasco,” one provider in Virginia said. “Overall, things appear to be normalizing, but there are still some unresolved issues.”

Multiple representatives of Humana Military did not respond to requests for comment.

What happened?

The roots of the TRICARE challenges reach back years and years.

DHA announced it had awarded the “new T-5 contracts” to Humana Military, a part of the Louisville, Kentucky-based managed care organization, Humana Inc. (NYSE: HUM), and TriCare Healthcare Alliance in December 2022. Humana has engaged with the U.S. Department of Defense since 1996, the company said. In 2011, DOD awarded a contract to Humana to administer the now-defunct TRICARE South region. The TRICARE regions were fused to simply include East and West for the 2016 contract awards; Humana won the contract for the East region in 2016.

Along the way, Humana Military has engaged with various subcontractors to handle the technical aspects of billing and claims processing. One contractor included PGBA, a part of the team of contractors that Humana included in its pitch for the TRICARE contract. PGBA replaced Wisconsin Physicians Service (WPS) as Humana’s claims processor. However, PGBA has been a partner for Humana in its previous TRICARE contract awards. Based on providers’ observations, one key hiccup was that the claim system could not reconcile claims and provider profile data for operators and organizations in the PGBA system before the current contract period.

Additionally, there were hangups in getting digital claims submission and payment processing correct. One subject matter expert told ABN that Humana Military offered payment advances on pending claims. While seen as a good faith effort, this person said, it has led to another point of irritation with providers.

“It’s just that people are really mad because as soon as claims started to process, [Humana] started to reconcile [payments with the advance],” this person said. “They went weeks without getting paid and [Humana] is taking back claim dollars from literally the first things that are going through. So, they’re still not getting paid even though they’re getting processed.”

The situation may distress some autism therapy providers beyond the crisis of the last few months. Organizations across all regions of TRICARE note that care rates, even if a smaller portion of a provider’s revenue, aren’t at the levels that lead to padded balance sheets. Meaning, some organizations may stop working with TRICARE patients or face the likelihood of being forced to shut down.

The biggest concern among providers

All sources consulted for this story worry that the TRICARE contract transition snafu will limit access to services for the program’s members. A near second to that, they worry about the prospect that autism therapy providers may shut altogether, further complicating the access challenges for the industry.

Earlier in the year, some providers in the East region said their business demise was a distinct possibility.

“If I have to give my clients a heads up and tell them I have to shutter, I can’t continue, then they’re going to have to go back to waiting lists, and that can be six months and up to a year just to get another therapist in the door for them,” one provider said in February.

Others also worry that fewer autism therapy providers will lead to limited job prospects in regions with large TRICARE populations. With fewer organizations in those communities, there are fewer job opportunities. And with the cash flow crunch created by the flubbed contract transition, organizations that will weather the storm won’t have the resources to hire staff hitting the market due to closures. That assumes that clinicians will want to come back or come to the TRICARE slice of the autism therapy industry at all.

“So, now we have all these kids — my phone is ringing off the hook and they’re asking, ‘Do you have any openings?’ And I don’t, and I won’t, not because I don’t want to, but also because we’ve been trying to hire,” one provider said. “Who wants to come work within this program right now?”