Tricare's stance has not made it impossible to get cognitive rehabilitative. But it has discouraged civilian clinics from treating soldiers.
In interviews, several clinic owners and medical directors described their frustrations.
On some occasions, they were paid after developing relationships with individual Tricare claims processors or case managers, only to have the arrangements fall apart if the person left.
"We have tried to get Tricare and just beat our head against the wall," said Brent Masel, the president of the Transitional Learning Center in Galveston, Texas. "It took forever to get paid. It was always a fight."
Mark Ashley, the president of the Centre for Neuro Skills, a chain of rehabilitation clinics, said Tricare and other insurance providers were unwilling to pay because those with brain injuries can often perform basic functions that let them get through their daily lives.
They are "able to walk around, able to maneuver, but can't function cognitively in a manner that's safe, appropriate or competent," said Ashley, a past president of the brain injury association. "We can fix much of that, but it takes an exhaustive amount of time and effort. That's where the payers are out of touch."
One of the nation's top brain injury centers set up a charity program to help cover gaps left by Tricare. Susan Johnson, who runs Project Share at the Shepherd Center in Atlanta, said Tricare pays only about 40 cents of each dollar of care provided for the type of comprehensive program that the clinic has found successful. The rest comes from Bernie Marcus, a billionaire philanthropist, and income from inpatient services.
"These guys go and they put their lives on the line and we put them in this situation that's difficult for some and less difficult for others to get care," Johnson said. "I find it frustrating."
Other clinic owners said they were able to game the system by providing cognitive therapy, but billing for other Tricare-covered services — putting them at risk of being accused of false billing.
One clinic manager acknowledged being "creative" when submitting bills to Tricare. He said that he submitted bills to Tricare for occupational therapy when the treatment focused more on improving memory.
"They won't pay for this, but they will pay for that," said the manager, who did not want to be identified for fear of damaging his ability to receive payments. "You just have to figure out how to work the system."
Soldiers and families agreed that Tricare's stance has made getting care a battle.
Sarah Wade said she patched together adequate care for her husband Ted, arranging for him to go to a VA hospital for some services and to travel to Walter Reed Army Medical Hospital for others.
Tricare would have paid for some things, such as a physical therapist to help him learn to walk again. But she has had no luck trying to persuade Tricare to pay to treat his brain injury.
hide captionSarah Wade, 36, has been arranging for medical care and fighting to receive treatment for her husband, Ted, 33, who suffered a traumatic brain injury while serving in Iraq.
Sarah Wade, 36, has been arranging for medical care and fighting to receive treatment for her husband, Ted, 33, who suffered a traumatic brain injury while serving in Iraq.
In frustration, Wade personally visited a high-ranking official at the Veterans Affairs Department. He, in turn, ordered a VA hospital to fund a special contract with a local civilian rehabilitation doctor near the Wades' North Carolina home.
"Yes, we have been able to get [cognitive rehabilitation] paid for, but it's been with a lot fighting, red tape, and bureaucracy," Sarah Wade said. "It's his greatest injury and the one that impacts his life the most, that impacts his ability to be a human." She added, "It shouldn't be this hard."
The Wades credit the rehabilitation that Ted has received with markedly improving his cognitive problems. After his 2004 injury, Ted spent months regaining consciousness. Doctors were unsure about his mental state, not certain he would ever talk or even think rationally.
Today, Ted speaks in slow, sure sentences, even cracking jokes. He can make decisions — choices that seem simple enough to someone with normal cognitive skills, but which often stymie those with brain injury.
He knows, for example, to buy cherry tomatoes at the store rather than big tomatoes, which are hard for him to chop and slice with only one arm. He can read through a menu, and pick food that's nutritious. He can wash and fold his own laundry.
One recent day after dining at a Mexican restaurant in Washington, Ted smiled when Sarah reminded him that he was once unable to figure out whether he liked hot sauce on his tacos.