Texas Attorney General Ken Paxton has launched an investigation into TriWest Healthcare Alliance Corp. over allegations that the company wrongfully denied health care claims for TRICARE beneficiaries.
The investigation follows a rise in complaints alleging TriWest incorrectly denied claims by falsely determining that patients had other health insurance, according to the Office of the Attorney General.
TriWest is a private company that contracts with the federal government to administer health care programs for military members, veterans and their families. The company manages the U.S. Department of Veterans Affairs Community Care Network and serves as the support contractor for the Defense Health Agency’s TRICARE West Region.
Investigation Follows Consumer Complaints
The OAG said it has received reports that TriWest denied health care claims after incorrectly identifying patients as having other health insurance, also known as OHI.
The agency cited one case involving a Texas couple, the Shoemakers, who together served for more than 20 years. Mr. Shoemaker was undergoing cancer treatment when TriWest allegedly classified his vision plan as other health insurance.
The classification resulted in denials of claims for medical treatments and appointments, according to the OAG. The Shoemakers reportedly spent nearly two years attempting to resolve the issue with TriWest before receiving relief after NBC reported on their situation.
The attorney general’s office said the Shoemakers’ experience was not unique and that TriWest has acknowledged problems involving OHI-related claim denials.
Paxton Warns Insurers Against Deceptive Practices
“Health insurance companies cannot promise health care coverage and then wrongfully deny patients the benefits they are entitled to receive,” Paxton said.
“I will not allow health insurance companies to take advantage of Texans through deceptive or unlawful practices. If TriWest broke the law or wrongfully denied patients care, we will use the full force of the law to stop them.”
The investigation will examine whether TriWest’s conduct violated the Texas Deceptive Trade Practices Act.
OAG Issues Investigative Demands
As part of the investigation, the Office of the Attorney General issued Civil Investigative Demands to TriWest.
The agency also plans to interview consumers and company employees as it examines the allegations and determines whether unlawful or deceptive practices occurred.
The investigation remains ongoing, and investigators have not determined that TriWest violated Texas law.
