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NORFOLK, Va. — A recent change to claims processing through Humana Military, the primary healthcare program used by active duty military, has led to weeks of unpaid insurance claims for mental health providers across Hampton Roads.
13News Now received messages from mental health counselors that providers within TRICARE East, underneath Humana Military, are sitting on weeks of unpaid insurance claims for the entire month of January.
13News Now confirmed that on January, 1 2025, Humana Military switched the company it utilizes for claims processing from WPS Health Insurance to PGBA.
Since then, licensed professional counselors and mental health clinicians may not have been paid for client services, based on a new reporting requirement through PGBA.
“Now, we as clinicians are stuck saying ‘so sorry’ to our clients we’ve seen for years in crisis. That, ‘okay, we can’t see you because your insurance is denying every claim.’ It’s absolutely unfair,” said Alice Conner, who is a mental health counselor based out of Virginia Beach.
Conner, who estimates between a third to half of her clients are covered under TRICARE, says she’s sitting on more than dozen claims for the month of January that have not been resolved. She says it equals thousands of dollars, and that many mental health clinicians in the region are experiencing the same dilemma.
Starting January 1, claims must be signed off by a licensed physician or physiatrist, a requirement that Conner says has never been implemented before. Without that authorization, claims since the new year have been denied.
“That’s unheard of. That’s not required. We’re licensed and independent, the TRICARE policy says that’s not required. Never has been required, suddenly we make that a new rule,” Conner says.
A spokesperson for Humana Military responded:
We acknowledge that our typical timeframes for processing claims have been delayed as a result of this major system transition, however, as of today, a very small percentage of claims submitted (0.4%) have gone beyond our contractual payment timeframe of 30 days.
Claims have started flowing through the processing systems and payments have begun. We do continue to work urgently through the remaining systems issues. At this time, we anticipate those remaining issues will be fixed in the next couple of weeks.
Another mental health clinician based in eastern Virginia, who wished not to be identified, said this change is having an “enormous ripple effect on clinicians and service members.”
“Clinicians will begin to have to stop taking new TRICARE clients, which I have done, and then pause services for TRICARE clients until payments are restored,” they said.
Currently, Conner said many counselors may be forced to stop seeing TRICARE clients unless they pay out of pocket for their appointments. However, clients may be forced to stop seeking help in return, because of an inability to afford mental health care on their own without coverage.
“They cannot afford out of pocket, and we can’t afford pro bono. We have to keep the lights on, pay our own families. It leaves us in a heartbreaking situation as clinicians,” she said.
The Humana spokesperson added they are sending advance payments to the “most vulnerable providers” who have submitted claims.
13News Now is awaiting a response back from PGBA.