Pursuing medical care costs on behalf of Uncle Sam
The Claims Branch, Fort Gordon Office of the Staff Judge Advocate, does not just pay claims for damages caused by the government; it also collects money on behalf of the government. The Claims Branch’s collection efforts on behalf of the government, known as affirmative claims, consist of recovery for medical care costs, damage to Army property, and damage to Soldiers’ property by carriers and warehouses.
During fiscal year 2013, the Fort Gordon medical care affirmative claims specialists pursued and recovered more than 320 medical care claims, obtaining more than $697,000 for the federal government; more than $350,000 of which was deposited directly into DDEAMC’s operating fund. The remainder was provided to TRICARE. These deposits represent the costs of medical care provided to active duty Soldiers, retirees, and family members by DDEAMC and TRICARE health care providers.
Active duty service members and TRICARE beneficiaries do not pay for the medical care they receive in military hospitals or through TRICARE. Their care, however, is paid for by the government. Federal law requires the federal government to recoup its medical expenses for treating those who are injured due to another’s negligence or those who are covered by private health insurance. The United States recovers those expenses directly from the at-fault party or its insurer. The Army does not recover or attempt to recover medical care costs from Soldiers, retirees or their family members.
In addition to the medical care costs, the affirmative claims specialists determine how much of the injured Soldier’s duty time was lost due to the injury. In conjunction with the medical care claim, a claim is asserted against the at-fault party to recover the wages paid by the United States during the time the Soldier was unable to perform military duties due to the injury. The recovered wages are deposited in the operations and maintenance fund of the Soldier’s unit.
The Fort Gordon medical care recovery process is started by the affirmative claims paralegals working at DDEAMC who obtain notice of a potential claim through their daily review of treatment records at the hospital. They may also receive notice of a potential claim from an attorney representing a Soldier or TRICARE beneficiary injured in an accident who is seeking information concerning his client’s medical care. The paralegals send a letter and questionnaire to the patient or family to obtain information concerning the treatment. The letter explains that the requested information is used solely to pursue medical costs from the party responsible for the injuries or the insurance company. The letter stresses that the Army will not attempt to recover these costs from the Soldier, the retiree or family member.
Army regulations require that Soldiers and other TRICARE beneficiaries cooperate in recovering the costs of their treatment by providing the information concerning the facts and circumstances surrounding the medical care. Upon obtaining the requested information, the DDEAMC business office and paralegals determine the cost of the care caused by the accident and the amount of pay the injured Soldier received during the time his injury prevented the performance of his military duties. The DDEAMC paralegals then assert a claim against the at-fault party or its insurance company to recover the United States’ loss.
The following example illustrates the typical medical care recovery claim process:
A speeder fails to stop for a red light and collides with a car driven by Sgt. Casey Smith, an active duty Soldier. Smith is taken to the DDEAMC emergency room where the Soldier is treated. The next day, the DDEAMC claims paralegal sees the treatment record while reviewing the emergency room records.
Based on the treatment record, the paralegal determines that a potential claim exists. The paralegal begins collecting the information necessary to assert a claim for the medical care costs and lost wages. The collection of this information includes contacting Smith to obtain the circumstances of the accident, as well as obtaining the speeder’s insurance information and the police report. The total bill for the medical care is obtained from the hospital’s Uniform Business Office. Based on how much duty time Smith lost due to the accident, the affirmative claims specialist calculates the amount of wages paid to Smith during the time unable to work. A claim for the total bill, medical costs and lost wages, is asserted against the speeder’s insurance company. The recovered medical costs are deposited in DDEAMC’s operating budget if all the treatment was provided by DDEAMC. If Smith was also treated by a TRICARE participant, the amount recovered that is attributable to TRICARE is forwarded to TRICARE. The recovered wages are deposited in Smith’s unit operations and maintenance fund.
This process places the cost of providing medical care to TRICARE beneficiaries where it belongs – on the at-fault party.
If a person is injured, their cooperation with the process will greatly assist the Army in receiving payment for their care and, ultimately, in improving the health care available for all TRICARE beneficiaries.