Medical - At the Academy

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LurkingQuietly

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Thought I'd ask this question here before posting it to the parents FB page. My DS (finishing 2nd class year) needs to have some minor day surgery. Doctor at the academy wants him to have it done next semester(Fall). I told the DS to have it done the week before he goes back to school so he could recover at home. Dr didn't think it was possible, and wants to do during the school year. DS thinks he can do it the week of convocation.

Anyone have any suggestions? Advice? Where do they do day surgery at? Could it be done in his home state?
 
LurkingQuietly said:
Thought I'd ask this question here before posting it to the parents FB page. My DS (finishing 2nd class year) needs to have some minor day surgery. Doctor at the academy wants him to have it done next semester(Fall). I told the DS to have it done the week before he goes back to school so he could recover at home. Dr didn't think it was possible, and wants to do during the school year. DS thinks he can do it the week of convocation.

Anyone have any suggestions? Advice? Where do they do day surgery at? Could it be done in his home state?
Click to expand...

My 2/c just recently had shoulder and elbow surgery with the contracted CGA orthopedist. Send me a private message if you want to discuss this.
 
Your DS is covered under Tricare, specifically under the Tricare Prime option.

As you may know, Tricare is the military's version of an HMO so there are rules in play to that helps with cost containment.

The clinic at the USCGA is small so it is staffed to provide only primary care. Basically, the "direct care" it provides is what you can get from your local family medicine or internal medicine doctor. Almost all specialty care required by those at the USCGA is "purchased care" in that the military relies on the local medical network to provide when needed.

In the case of your DS, the same day surgery would be provided in the local network by a specialist in the local Tricare network.

The problem with your DS doing it at home is the provider (and facility) that will do the procedure will most likely not be in the New London, CT Tricare network (you don't happen to live in that area, do you?). Your DS's primary care manager (PCM) is at the clinic at the USCGA. He/she can refer to specialists only in the local network. If the PCM needs to refer to specialists outside of the local Tricare network, then special approval will be required (e.g. someone assigned to the USCGA with cancer needs to be seen at Memorial Sloan Kettering Cancer Center in NYC).

It is not the norm for a PCM to refer patients outside of the local network for non-emergency care like the kind your DS is facing. Put another way, if your DS was spending the summer at home (let's say Casper, WY) and he breaks his arm. The ER doctor thinks he needs to see an orthopedic surgeon. His PCM at the USCGA would have to write a referral for Tricare to approve that specialty care. In this case, it would be approved because your DS broke his arm and he needs (no question about it) to be seen by an orthopedic surgeon.

In the case you present, your DS's PCM can write a referral for him to be seen for the surgery near your home. However, Tricare probably won't approve it because the specialist is not in the Tricare network in the New London area AND there is no compelling reason for him to be seen at home other than for convenience.

You can try to get the procedure approved. Your DS will just need to ask his PCM at the clinic to write the referral for someone near your home. You have to make sure though that the specialist near your home is in the Tricare network. Again, probably won't be approved because it's more for convenience than for a clinical reason. Because his doctor doesn't think it's possible, then he may not be willing to write a referral to get the procedure authorized near your home anyway.

What procedure does he need done?
 
whose insurance will be used? DS’s from USCGA or your private insurance?
 
Tricare (from USCGA) will be used IF approved.

If he is covered under a parent’s private insurance then that’s an option that can be used to bypass Tricare altogether.
 
GoCubbies said:
Tricare (from USCGA) will be used IF approved.

If he is covered under a parent’s private insurance then that’s an option that can be used to bypass Tricare altogether.
Click to expand...

Even if the cadet wishes to use private insurance and assume all treatment costs, they must not be rendered to a duty status other than "Fit for Full Duty", and must receive medical counseling from the Academy's Health Services Division and acquire Command approval for such treatment pursuant to USCGA Corps of Cadets Regulations.
 
GoCubbies said:
Your DS is covered under Tricare, specifically under the Tricare Prime option.

As you may know, Tricare is the military's version of an HMO so there are rules in play to that helps with cost containment.

The clinic at the USCGA is small so it is staffed to provide only primary care. Basically, the "direct care" it provides is what you can get from your local family medicine or internal medicine doctor. Almost all specialty care required by those at the USCGA is "purchased care" in that the military relies on the local medical network to provide when needed.

In the case of your DS, the same day surgery would be provided in the local network by a specialist in the local Tricare network.

The problem with your DS doing it at home is the provider (and facility) that will do the procedure will most likely not be in the New London, CT Tricare network (you don't happen to live in that area, do you?). Your DS's primary care manager (PCM) is at the clinic at the USCGA. He/she can refer to specialists only in the local network. If the PCM needs to refer to specialists outside of the local Tricare network, then special approval will be required (e.g. someone assigned to the USCGA with cancer needs to be seen at Memorial Sloan Kettering Cancer Center in NYC).

It is not the norm for a PCM to refer patients outside of the local network for non-emergency care like the kind your DS is facing. Put another way, if your DS was spending the summer at home (let's say Casper, WY) and he breaks his arm. The ER doctor thinks he needs to see an orthopedic surgeon. His PCM at the USCGA would have to write a referral for Tricare to approve that specialty care. In this case, it would be approved because your DS broke his arm and he needs (no question about it) to be seen by an orthopedic surgeon.

In the case you present, your DS's PCM can write a referral for him to be seen for the surgery near your home. However, Tricare probably won't approve it because the specialist is not in the Tricare network in the New London area AND there is no compelling reason for him to be seen at home other than for convenience.

You can try to get the procedure approved. Your DS will just need to ask his PCM at the clinic to write the referral for someone near your home. You have to make sure though that the specialist near your home is in the Tricare network. Again, probably won't be approved because it's more for convenience than for a clinical reason. Because his doctor doesn't think it's possible, then he may not be willing to write a referral to get the procedure authorized near your home anyway.

What procedure does he need done?
Click to expand...


Thanks......This is a really good explanation of how their health coverage works. He needs his tonsils out. They were so bad that the CGA clinic sent him to the local ER.
 
You should also know that the follow-up for tonsillectomy and adenoidectomy is anywhere from 2-4 weeks post-op when he will have to see the surgeon (usually an ears, nose, & throat specialist) again.

You have a couple options:
1) have the procedure authorized at home with enough time so he can see the same ENT specialist for that follow-up before returning to school
2) he can have the procedure at home and have the follow-up when he returns to school

Option#2 is not ideal. Typically, surgeons like to do follow-ups on their own work. An ENT specialist in the New London area could see your DS for a follow-up but I'm sure he'd prefer the operating ENT do it instead

As I mentioned in my first post, it wouldn't hurt to try to get the procedure authorized to be done near your home, but it's not a slam dunk Tricare would authorize it.

I echo what @alaska66 recommended. If you do decide to do this procedure outside the military health care system (e.g use private insurance), then you should let someone at the USCGA headshed know and get the appropriate approvals first.
 
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