May 1, 2013 Updated: May 1, 2013 at 8:50 pm
Medical providers across the Pikes Peak region say a new Tricare contractor in place since April 1 has caused massive delays in patient care for military families - leaving patient referrals in limbo for weeks and some health care specialists at risk of being laid off.
While the issue stretches across the western United States, it is magnified in El Paso County, where about 171,000 troops, veterans and their dependents rely on the new Tricare contractor, which offers the military's equivalent of civilian health insurance.
On Wednesday, more than 30 employees of private health care providers voiced their concerns about the new Tricare management firm, UnitedHealthcare to Rep. Doug Lamborn, R-Colo., during a meeting at his office in Colorado Springs. Sen. Mark Udall, D-Colo., also released a statement vowing to help fix the issue.
Providers' complaints about the process of doctors referring patients to specialists, as well as insurance reimbursements.
Referrals have taken weeks - rather than a couple days - to clear UnitedHealthcare's system, providers said. Those referrals run through UnitedHealthcare also have been missing rudimentary information, including patients' diagnosis.
For instance, Falcon Physical Therapy received 93 referrals to its four Colorado Springs offices during the last week of March, said Lorne MacDonald, the company's founder.
Those four clinics received 11 since, he said.
Some specialists said they have been unable to access UnitedHealthcare's website to view whether insurance claims have been approved.
And insurance reimbursements have been denied or come late, leaving providers strapped for cash or contemplating layoffs - including MacDonald.
'They (UnitedHealthcare) supposedly are putting a lot of people ... on the problem to fix this, ' said Lamborn, referencing a conversation with the company's chief executive officer. 'However, I want to see results. This is unacceptable. '
'Less than ideal'
The issue stems from a decision by the Defense Department in March 2012 to award Tricare's contract for its western region to UnitedHealthcare.
Tricare is a health care program offering insurance to active duty troops, veterans and their dependents, and its western region covers parts or all of 21 states, including Colorado.
TriWest had owned the contract for 16 years and protested the decision. The U.S. Government Accountability Office, however, denied the appeal in July 2012.
The decision spurred UnitedHealthcare to announce the creation of 230 jobs for a call center in Colorado Springs - as well as other jobs across the U.S.
The transition in taking over coverage for the 2.9 million people formerly with TriWest has not gone smoothly, said Matt Peterson, regional chief executive officer for UnitedHealthcare Military and Veterans.
'Obviously, this is less than ideal, ' Peterson said. 'And we obviously apologize to everybody for these operational challenges, as again, they are not where we want to be at this time. '
The delays are expected to be fixed by June 1, Peterson said, meaning referrals would be processed in a couple days, as was the case under TriWest.
In the meantime, the company has offered unlimited overtime to its employees, and has reached a capacity level where they can start 'knocking down the inventory, ' Peterson said.
'But we're not perfect at this, and we're not doing as well as we should be and we're going to remediate that, ' Peterson said.
The delays have kept patients waiting for services including physical therapy and sessions with psychologists, providers say.
In one case, the insurance authorization for a man who had surgery on his rotator cuff was submitted to UnitedHealthcare on April 5, MacDonald said. It took about two weeks to receive a response, he said.
Referral paperwork from UnitedHealthcare had been sent through the postal service - not a fax machine - he said, and it was missing authorization numbers and the name of the doctor who made the referral, as well as specific diagnosis.
In the case of the man whose rotator cuff was torn, the wait likely lengthened the man's recovery time, MacDonald said.
'If you don't move it, it will stiffen up, ' MacDonald said. '... so it's devastating for the patient. It's bad enough on us, financially. '
Dr. Chris Phillips, a psychologist specializing in combat trauma, said he has not received an insurance check since the transition to UnitedHealthcare - a widespread complaint among health care providers at Wednesday's meeting with Lamborn.
Phillips has delayed some appointments and begun working pro-bono for several soldiers, living off his savings in the meantime.
At Colorado Springs Gynecology Associates, no insurance checks have arrived since April 7, said Hannah Wood, the administrative director. A handful of women are waiting to receive implanted birth control, while one woman is awaiting surgery and five women's prenatal care visits have been put on hold, Wood said.
'Nothing really got accomplished, but I am thankful that he put forth the effort, ' said Wood, after the meeting with Lamborn. 'It doesn't seem like anything's going to be fixed anytime soon. '
UnitedHealthcare's woes come as the military plans to furlough its civilian doctors and clinicians - likely transferring some of that case load onto the private sector.
Beginning in June, the Defense Department expects to begin placing thousands of civilians on furlough for 14 days under cuts known as sequestration.
With civilian clinicians available fewer days of the week, more patients could be referred to private specialists, said Col. John McGrath, commander of Fort Carson's Evans Army Community Hospital.
Already, physicians refer thousands of Tricare beneficiaries from military medical offices to their private-sector counterparts each year.
In 2012, for example, those physicians made more than 38,100 referrals to specialists for physical therapy, urgent care, gastroenterology, behavioral health and dermatology - the five most costly referrals that year.
The cost of those referrals totaled more than $13 million.
'Sequestration, when it hits in June, will decrease our capacity, ' McGrath said. 'So we know that we're going to push more people to the (private) network. And we just want to make sure there's a network there to push it to. '
Every day, doctors and clinicians at Fort Carson and local Air Force bases refer patients to civilian specialists. Here are the average number of referrals each month for the top five conditions in 2012, as well as the average monthly TriCare costs for each condition.
Physical Therapy: 825 referrals; $468,919
Urgent Care: 1,397 referrals; $184,764
Gastroenterology: 232 referrals; $157,070
Behavioral Health: 380 referrals; $145,916
Dermatology: 341 referrals; $130,982
SOURCE: THE DEFENSE DEPARTMENT'S COLORADO SPRINGS MULTI-SERVICE MARKET OFFICE