Texas Attorney General Ken Paxton is investigating TriWest Healthcare Alliance over alleged improper denials of TRICARE claims.
Nonprofit health plans and university hospital systems own TriWest, a private company and government contractor that manages health benefits for military members, veterans and their families. This includes work with the U.S. Department of Veterans Affairs Community Care Network and the Defense Health Agency’s TRICARE West Region.
The investigation resulted from reports and admission of possibly problematic denials, a Sept. 1 news release from the attorney general’s office said. The news release said there have been allegations of TriWest falsely claiming beneficiaries have other health insurance, leading to denials.
As an example, the attorney general’s office said a Texas cancer patient had coverage for treatments and appointments denied due to TriWest incorrectly considering his vision plan as other health insurance.
The investigation aims to determine whether violations of the Texas Deceptive Trade Practices Act took place. The process entails Civil Investigative Demands — subpoenas issued by government agencies — as well as interviews with consumers and company employees.
“I will not allow health insurance companies to take advantage of Texans through deceptive or unlawful practices,” Mr. Paxton said. “If TriWest broke the law or wrongfully denied patients care, we will use the full force of the law to stop them.”
Following an NBC News investigation in May, TriWest President and CEO David McIntyre Jr. issued an apology to beneficiaries, taking accountability for challenges with other health insurance.
“While TriWest is required to gather information on OHI, I understand that some beneficiaries’ claims incorrectly reflected that they had OHI, which resulted in the claims initially being denied — as well as delay and frustration,” he wrote. “What’s more, the encounters for some with our customer service operation were not efficient or effective. This is not acceptable, and our team has been working diligently to fix this issue.”
TriWest told Becker’s it is reviewing the Civil Investigative Demand.
“We are committed to the military families across Texas and helping ensure they receive the care they have earned,” TriWest said.
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