U.S. Military Retirees of the Philippines Group

Tricare Philippines Newsletter 15002

TRICARE Knowingly and Blindly Pays for Fraudulent Care, Phase I Demonstration Survey Results are Secret
 
Fraudulent Claims Payment

Tricare system for catching payment mistakes flawed. This Stars and Stripes article addressing a recent General Account Office report finally exposed what we have known for years.

By 2010 we were well aware of a number of questionable activities, if not fraud, involving International SOS in the Philippines. Because of this our group used the Freedom of Information Act (FOIA) to request information on the unique Philippine TRICARE program including claims data for 2009 for TRICARE payments in the Philippines. It took more than a year to obtain the data due to the TRICARE Management Activity’s (TMA) foot dragging. Finally in 2011 we received what TMA said was claims data for 2009. It appeared TMA intentionally failed to include data for the last 15 days of the fiscal year and mixed in data from other years and this was presumably done in an attempt to invalidate the data. Either that or one has to conclude they were incapable of working with their own data. However we discovered their failures or deliberate acts and were able to make adjustments so we could still use the data and draw valid conclusions.
Here is just some of what we found.
  1. We were told by sources that ISOS paid cash for Prime Remote care and then submitted claims for reimbursement in kind of a revolving account process. We confirmed this was how the contract operated based on DODIG report D-2008-045, Page 45, Appendix D.
  2. We were told claims were filed for amounts well in excess to what was really paid using fake receipts with the excess going into the pockets of ISOS and employees alike. We found that the average amount billed per visit for Prime was $179 while $36 was the average amount billed for TRICARE Overseas Standard. We also found the average amount billed per bed day for Prime was $539 while for TRICARE Overseas Standard it was $190 and TRICARE paid on average $249 per bed day for Prime vs $82 for TRICARE Overseas Standard. All the while this was going on TMA was proclaiming TRICARE Overseas Standard beneficiaries and their providers were defrauding TRICARE but not a word about Prime Remote.
  3. We were told numerous fake claims were filed to increase the take, so to speak. We found that Prime Remote patients averaged 11 visits compared to 2 visits for TRICARE Overseas Standard. Further we found that Prime Remote patients were admitted on average of 2 times compared to 0.16 times for TRICARE Overseas Standard. Further, comparing utilization rates for Philippine Prime Remote to U.S. utilization rates we found the following.
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


















All of this and more was documented in a study and submitted to TMA. We made a recommendation that they should take a random sample of the providers for Prime Remote patients and confirm with the providers they actually saw the patient and that the billed amount was what they actually billed and was paid for the care based on the claim information submitted to TRICARE by ISOS. We also suggested they contact Prime Remote beneficiaries and confirm they were admitted x times in one year or seen by providers xx times in a year based on the claims data to confirm or disprove the high utilization rates.

To our knowledge this was never done and the information, backed up by their own claims data, was ignored. However when the new contract came into being the provision for ISOS to pay the claims and submit claims was quietly removed.

Now the General Accounting Office finally discovered what we knew and reported to TRICARE four years ago. Quoted from the article above, “The Defense Health Agency’s ‘basic process of reviewing claims has not changed in 20 years,’ the report stated. ‘As a result, DHA continues to only identify improper payments due to contractor compliance problems.’

The Defense Health Agency concurred with the GAO findings. A brief response letter explained that Tricare would need an unspecified amount of time to discuss how to make changes to its improper payment measurements and methodology.”

As we have found for many years the Defense Health Agency (DHA), formerly the TRICARE Management Activity (TMA), always concurs with all negative findings against them. Then proceeds to say they will comply but never with a timeframe. Sooner or later they will just ignore the findings and promised corrections. We have seen this time and again. One recent example is when they promised the DODIG that they were already in the process of hiring a local employee to comply with the DODIG’s recommendations. Yet their promise failed to come true and when
questioned manufactured lies about why the position was not filled.

We fully expect to see the same game of back peddling and lies in this case as well. After all lying has become the
standard within the military.

Demonstration Survey Results

The Defense Health Agency (DHA) has decided the details and results of the Phase I Demonstration Survey will not be released to beneficiaries. Apparently only Congress and the DODIG will be allowed to see them. That’s not surprising to us given the initial secrecy surrounding the denial of legitimate users of the Demonstration to participate in the survey. It became clear that those responsible for the survey were not interested in the opinions of those that were forced into this limited access to care program. Because of the lack of real input we have to assume the secret results will reflect what DHA wants Congress and the DODIG to believe. Otherwise there is absolutely no reason to hide the results from those that are most affected by them. See
Confirmed: The Results of the Demo Survey are Secret/Classified.

If you want to find out the real story behind DHA’s and ISOS’s focused attack on TRICARE beneficiaries in the Philippines instead of their spin and propaganda, read TRICARE: Betrayal in the Philippines, Is This the Future of TRICARE Overseas? It is available at the link and most online book sales outlets such as iBooks, Barnes & Noble, Amazon and others.
 
What’s Next?
 
As we gather more information from DHA, the contractor and beneficiaries we will continue to send out newsletters but generally not more than once a month.
 
What we continue to see is rapidly put together policy that sometimes changes within a few days only to be changed again. These in turn raise new issues or other unforeseen problems surface. To keep up with these we will post shorter topic specific updates and notices on our blog,
TRICARE Overseas Philippines Blog. Recommend those interested in keeping informed on Philippine TRICARE Standard and the Demonstration check it frequently or alternately add your email address and click “Follow” about midway down the front page and on the right. This will automatically email you a link to each new entry.
 
Archived Newsletters
 
Previous Newsletters can be accessed by going to
U.S. Military Retirees of the Philippines Group TRICARE Newsletter Archive. If you want to access an older Newsletter that has dropped off the archive list see Links to Old Newsletters.

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