Texas attorney general investigates TriWest over disputed TRICARE denials
Ken Paxton’s office is examining whether TriWest improperly denied TRICARE claims tied to other-insurance records.
By Deshawn Carter · Sports Writer
3 min read
The Texas attorney general investigates TriWest after complaints that the military health care contractor wrongly denied TRICARE claims by incorrectly listing some beneficiaries as having other health insurance. Attorney General Ken Paxton announced the inquiry on Sept. 1.
Paxton’s office has sent TriWest Healthcare Alliance civil investigative demands and plans to interview consumers and employees. The state is examining whether the company’s practices violated the Texas Deceptive Trade Practices Act, according to the attorney general’s office.
The action is an investigation, not a lawsuit, charge, finding of wrongdoing or penalty against TriWest.
Why is Texas investigating TriWest?
State officials said complaints had recently increased from people who alleged TriWest denied health care claims after wrongly determining that they had other health insurance, often called OHI. The attorney general’s office said TriWest had acknowledged that OHI-related denials were a problem.
TriWest is a private federal contractor that administers health programs for military members, veterans and their families. According to Paxton’s office, it manages the Department of Veterans Affairs Community Care Network and supports the Defense Health Agency’s TRICARE West Region.
The inquiry includes the case of Guy Shoemaker, a Texas man whose experience was cited by the attorney general’s office. The office said TriWest treated his vision plan as other health insurance and denied claims for cancer-related treatments and appointments. It said he spent nearly two years trying to correct the issue and received relief after NBC News reported on his situation.
That account is an example cited by the state, not proof that TriWest committed a broader legal violation.
What does other health insurance mean for a TRICARE claim?
Other health insurance is coverage a beneficiary has in addition to TRICARE, such as an employer, spouse’s employer or private plan. Official TRICARE guidance says that in most cases the other plan processes a claim before TRICARE. A claim submitted to TRICARE before that process is complete can be denied.
Texas is investigating a different alleged problem: that beneficiaries were inaccurately recorded as having other coverage in the first place.
TriWest told Becker’s Payer Issues that it was reviewing the civil investigative demand and was committed to helping military families across Texas receive the care they have earned. Becker’s also reported that TriWest President and CEO David McIntyre Jr. previously apologized for some claims that incorrectly reflected OHI, saying those errors led to initial denials, delays and frustration.
Beneficiaries who believe their OHI information is wrong can report updates to their TRICARE contractor. Official guidance also says a person can file a factual appeal with the regional contractor when TRICARE does not pay for covered care or stops paying for care that had been authorized.
This story draws on original reporting from NBC News.