Mass confusion is sweeping throughout the Southeast and North Carolina as medical providers wait for reimbursements from a new claims processor for military families.

Clinic owners and therapeutic specialists said they are not having claims processed for services provided to military families. 

The financial vacuum has created a hangup in operations for clinics and the patients they serve.

Helping children navigate their place in the world and handle complex social dynamics through play therapy is Megan Numbers' passion project for life.

“There are lots of kiddos in our practice that have trauma that they are working through that have clinical diagnoses, like generalized anxiety disorder or depression or ADHD, that they need to be seen every week,” said Numbers, who runs Play Therapy of the Pines.

Numbers, 39, uses playtime to help children learn to express themselves and overcome situations in life through a healthy lens.

The certified therapist was working on a recent day with a girl to overcome some tough issues as a child whose father is deployed away from home by incorporating clay as a representation of a bully in the child’s life and how she views it in her brain.

“They can understand it better and talk about it without feeling ashamed or, you know, more upset,” Numbers said.

These sessions with military families are in jeopardy. 

Numbers said it’s because she has not been reimbursed for services provided to clients since Jan. 1.

“The threat is that we're going to have to stop seeing clients until we're getting reimbursed. So most of our clientele is the military population and so that would discontinue or pause their services,” Numbers said.

Effective Jan. 1, Humana Military, the health insurance company contracted by Tricare East, rolled out a new claims processor called PGBA. 

The insurer confirmed it began notifying providers last September of the change.

A vast majority of retired and active duty military families rely on Humana coverage to implement Tricare’s military health care entitlement program designed by the Defense Health Agency.

But without PGBA processing claims, thousands of providers throughout the Tricare East Region, which includes 25 states from Florida to Maine, can’t pay employees. Numbers said it is putting her tens of thousands of dollars in the hole.

“We've already made that decision to give clients the option to either pay out-of-pocket while this is happening and to hopefully be reimbursed by Tricare for later down the road. But again, we don't know if and when that's going to happen,” Numbers said. 

Multiple providers said they have been affected and are considering temporarily closing, which is a widespread problem given the fact Tricare lists about 9.6 million beneficiaries.

Humana Military spokespeople owned up to errors made in the transition from WPS, otherwise known as Wisconsin Physicians’ Services, to PGBA.

Humana Military communications lead Nan Frient responded to questions about the issue in a statement. 

“In early January, Humana Military learned that a small percentage of providers’ records in the claims administration system contained outdated or incorrect data despite loading all providers’ current data into the system in preparation for the administration of the T-5 contract,” Frient said. 

According to the Congressional Research Service, the T-5 contract represents the next generation of Tricare contracts stemming from congressionally mandated reforms.

“This incorrect data has inhibited Humana Military’s claims administration system from processing claims submitted by impacted providers,” Frient wrote.

The DHA administers the Tricare program, which is housed under the Department of Defense, and was also contacted for comment. 

“DHA is aware of this issue and is looking into it,” DHA spokesperson Brenda Campbell said.

Yenaira Rodriguez sent her 7-year-old son Jatniel Rosario to a different clinic, Bilingual Therapy Services. He has autism and fights through cognitive and speech delays.

Rodriguez said their clinic had to cut back services until the payment processing issues are fixed.

“It’s stress that never goes away," Rodriguez said.

She worried the progress Jatniel made over the years will stop.

"Going private and trying to find another place is worse as well. We don’t have the money to pay out of our pocket," Rodriguez said.

As of Monday, Frient said claims have started flowing through the processing systems and payments have begun.

“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. 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.

"Importantly, we have made the business decision to send advance payment to the most vulnerable providers who have submitted claims. This is a payment to assist with cashflow for providers while we resolve the remaining systems challenges. Specifically, we are issuing an advance payment to many Applied Behavioral Analysis (ABA) providers and nonfacility behavioral health providers and are actively addressing escalated complaints with urgency," Frient said. 

However, Numbers said she has still not had any claims processed yet by the third party contractor. Multiple other providers confirmed the same.