Military families may soon see some of their TRICARE claims reprocessed to correct an error that charged beneficiaries two copays for the same medical appointment.

The fix would eliminate the patient responsibility for a network facility fee copay in addition to the copay for an outpatient office visit. After the transition to a new TRICARE claims processor on Jan. 1, 2025, some beneficiaries were mistakenly charged both copays.

Thanks to beneficiaries who shared their explanation of benefits (EOB) documents with MOAA, we were able to verify this claims processing issue and escalate it to the TRICARE contractors for resolution. Inaccurate claims are being reprocessed to reflect $0 patient responsibility for the network facility fee in conjunction with a network outpatient visit.

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Hospitals are allowed to charge patients a facility fee (on top of the charges for medical services) to help cover the high cost of running a hospital. Patients sometimes encounter facility fees when they receive outpatient care from a provider office attached to a hospital or medical center.  

As hospitals buy up physician practices, urgent care centers, walk-in clinics, and standalone surgery centers, patients are more likely to encounter a facility fee even when they receive care outside the hospital setting. 

The TRICARE copay construct, implemented in January 2018, rolled facility fees into the copay calculation for network outpatient visits. When a beneficiary has an outpatient visit, and both the provider and facility are in-network, the patient is responsible for only one copay for the office visit – there should be no copay for the facility fee.

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Families with recurring medical appointments noticed the change – for specialty visits that include facility fees, Group A retiree families on TRICARE Select saw their out-of-pocket costs increase from $51 per visit to $102 with the addition of the facility fee copay.

Impacted claims are being reprocessed, and beneficiaries should expect to receive new EOBs for those visits that indicate $0 patient responsibility for the facility fee charge.

Please note that if the provider is non-network or the facility is non-network, the patient is responsible for a copay for the network portion of the visit and a percent cost share for the non-network portion of the visit.

Once TRICARE reprocesses claims, medical provider billing offices may proactively apply an account credit or send a refund if the patient already paid the mistaken facility fee copay. Alternatively, impacted patients can contact the provider’s billing office to request a refund – be sure to provide a copy of the revised EOB that shows the $0 patient responsibility for the facility fee.

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TRICARE beneficiaries who receive an EOB for a date of service after Dec. 1, 2025, indicating a copay is owed for both an outpatient office visit and facility fee, should contact legis@moaa.org and MOAA can look into the issue.