Tricare Philippines Newsletter 13007
Ongoing Issues with TRICARE Demo and Standard in the Philippines
Because of the new and poorly documented Philippine Demonstration Project we have concentrated on its issues for the last few months. However all 11,000 plus beneficiaries living in the Philippines have to thoroughly understand two distinct and Philippine unique TRICARE plans in order to even hope to survive TRICARE in the Philippines. The first plan is Philippine TRICARE Standard and the second is called the Demonstration but best described as a mixture of Standard and Prime combined; generally the worst of both. Because the plans are geographically implemented they apply to everyone depending on where they are physically located at the time of care, not where they physically live or any other status. To make it worse the TRICARE Management Activity (TMA) and International SOS (ISOS) made a decision to offer limited training on the Demonstration to those located in the three Demo areas and absolutely no training to those that live outside but who have to comply with the new rules when they visit or pass through any of these areas.
This Newsletter will attempt to briefly address some the ongoing and current issues with both plans, referred to as the Demo and Standard below. To keep the size down we will make extensive use of links to documents that provide more detail to our comments for those that care to read them.
Provider Training Issues: International SOS (ISOS) is mandated to train Demo providers in the basic TRICARE benefit under Standard and the specific requirements to collect deductibles, copays and submit claims. They use a front known as Global 24 which is owned and operated by them and has no known local address or phone numbers. See Who or What is Global 24 Network Services, Inc. Really?
To date the so called “trainers” from ISOS have not been very successful. This poor training has a direct effect on every beneficiary that tries to use this program because this failure will result in lost benefits, denial of care and higher costs to beneficiaries.
Examples of Issues
1. Flu shots were declared by a Demo hospital, AUFMC, to not be an authorized benefit and patients were refused them unless they paid for the shot themselves. Calls to the contractor’s help desk resulted in the retiree being told to buy it himself. Follow-up with the hospital a week later showed that ISOS had failed to correct their training and flu shots were still not authorized under the Demo! See Flu Shots for more information.
2. In May beneficiaries discovered that they were required to sign blank claim forms or the wrong forms by Demo providers or be denied care. TMA has admonished patients not to sign blank claim forms for years and even claimed to congress that Philippine beneficiaries did it for kickbacks in the past. This was reported to TMA and ISOS who both agreed this would stop. But as of August it has not stopped and yet another example of the failure of TMA and ISOS to properly train their trainers and Demo providers. See Blank Claim Forms for a detailed explanation and Be Very Careful with Your Signature and the Demonstration for recommendations on what to do.
3. Ophthalmologists across the Demo and even at least some that are certified under Philippine Standard have been told to advise beneficiaries that lens implants, used during cataract removal, are not a TRICARE benefit and the beneficiary must pay for them in full at time of care. This misinformation appears to be pervasive across multiple facilities and providers in the Demo and even certified providers. More than two weeks after the original notification and more than a week after the second, providers have yet to be advised of the mistake by ISOS. This single training error can amount to a personal cost of more than $500. Many beneficiaries are not aware of all the details involving their benefit so, unfortunately, will take ISOS’s word as gospel and pay the price in lost benefits and not file a claim. See Lens Not Authorized for a more detailed explanation.
4. In January we discovered that local hospitals did not know how to apply deductibles and copays and therefore overcharged beneficiaries for their cost share. This training issue was addressed to TMA and ISOS at the time and beneficiaries were alerted to be extra vigilant when dealing with ISOS or their contracted providers. See Misinformation and Training on Deductibles by Global 24 aka ISOS
. In August, after my cataract surgery, I went to pay my cost share to the hospital for the use of their facilities and I had a portion left of my deductible that would be applied with the copay applied to the balance. They were unable to properly compute my cost share and attempted to overcharge me. I redid their calculations showing them the correct way but they doubted me because they were doing it as they were trained. After calling ISOS and discussing both calculations they were eventually told I was correct. Obviously ISOS and their front are still teaching the wrong methods to calculate cost shares even after the previous mistakes and 8 months later. See Cost Share Calculations.
Bottom line each beneficiary needs to know the rules and never depend on the TMA contractor or their contracted providers for the correct information.
Other Health Insurance (OHI) and the Demo
Even prior to the start of the Demo we addressed the use of PhilHealth with ISOS and as usual received a noncommittal response. In April we found that some beneficiaries were being denied use of the Demo, but still required to use the Demo or pay 100% of the cost of their care, by approved providers because they had PhilHealth. We addressed this to ISOS via their front Global 24. After multiple back and forth emails that amounted to stonewalling, we addressed the issue directly to TMA and were promised a policy statement; something that should have been done well before the start of this experiment. It has been five months and we are still being told a policy statement is imminent. In the interim others with PhilHealth have been denied access to Demo providers while others have been accepted without question while we languish around without an official policy and allowing every provider to do it their way. We highly recommend everyone with PhilHealth contact each of their providers and the hospitals to find out their individual policies before you actually need care and find you are denied access. See discussion of current status of OHI and the Demo.
Scalping of Beneficiaries by TMA and ISOS
Scalping is defined by businessdictionary.com as "Attempt to take maximum financial benefit of the scarcity of an item (such as tickets to a sellout show) by hoarding it." In our case illegally encouraging approved providers to increase their fees 2 to 5 times their normal fees to a captive group of patients are have been required to use only those providers that have agreed to this illegal practice. It was apparent from day one that ISOS encouraged and approved this practice which was confirmed by multiple providers to multiple retirees and in front of witnesses. TMA sold themselves out by proclaiming increases of up to 5 times normal fees was a worldwide practice and acceptable to them, even while prosecuting others for the same practice calling it fraud. Therefore one can only deduct that it is only fraud when TMA is not behind it. See our previous Newsletter, Alert: Deliberate Overcharges under the Demonstration (Closed Network) for ways to protect yourself from these illegal practices. The most recent hospital added to the Demo, Medical City, does not increase their fees for Demo beneficiaries as all the others have done. So maybe our past actions are having some positive effect on TMA and ISOS or maybe they are afraid of the consequences of their past actions.
Claims Not Filed for Care When Paid in Full by Deductibles
This continues to be a major issue which causes beneficiaries to receive no credit for deductible payments which means they are required to pay them over and over again and TMA and ISOS failed to include any requirement for providers that requires them to file a claim. It is completely up to them and assumed they will file a claim for reimbursement. But when they changed the rules and required we pay up front they removed that incentive. The only defense against this is to pay cash and file you own claim which also defends you against the illegal overcharges approved by TMA and ISOS. See, After Action Report, ISOS Demonstration Teleconference.
When an EOB is Not a Real EOB & Failure to Reimburse Deductibles and Copays as Promised
When TMA and ISOS unilaterally removed one of the major benefits of the Demo by changing the rules and allowing providers to collect deductibles and copays upfront, they agreed to reimburse beneficiaries for overpayments by sending them a check with EOBs. Here is what we have found to be the reality of this promise and also what we are finding are new and unpublished EOB rules. These responses came from ISOS.
EOBs are received that show that some amount of the provider billed amount is not allowed for example the billed amount is $100 and the allowed amount is $20. However there is no mention of the owed reimbursement of copays and no check. Inquiries about these EOBs have resulted in various explanations.
1. ISOS forgot to obtain all the information when they processed the claim so could not reimburse the beneficiary who should now go and fight multiple providers for refunds; providers that may claim that TMA is responsible to make the refunds or refuse.
2. The EOB is not really a final EOB because ISOS is waiting for the provider to comply with a request for more information. If that comes, a new EOB, paying more will be issued. If not apparently nothing will happen. Somehow the beneficiary should know this and then fight the providers for a refund. Bottom line the beneficiary has no idea because the interim EOB looks identical to every other EOB.
It is obvious that neither TMA nor ISOS prepared for Demo claims and how to pay refunds. In the few instances where a refund is made, checks arrive without explanation which is not only unprofessional but shows how poor their accounting system is. Processing claims without the required information and then passing the negative consequences to the beneficiary simply demonstrates how little they care for beneficiaries in the Philippines; you can bet that would never happen in the states. Issuing fake or interim EOBs that are not identified as such is also beyond belief but we have all of this in writing. See Examples of EOBs, Failure to Repay Overpayments and Summaries of Explanations from TMA for detailed examples.
Bottom line; everyone must check each and every EOB they get very closely and question every error, omission or the lack of reimbursement checks. Watch for duplicate payments of the same claim as we are finding as well as it is theft of tax dollars.
Philippine Standard Issues
Certified Provider List Issues
There are two Certified Provider Lists; an official one we cannot see and an unofficial one which is posted on the internet for our benefit.
1. At times providers disappear from the unofficial list but remain on the official list and claims are paid for these providers even if they are not on the unofficial list.
2. At times a provider is removed from the official list but continues to appear on the unofficial list and individuals using the provider in good faith finds their claims denied and told the provider is not on the official list.
3. Providers have been moved from the certified area to an area for providers not used in more than two years but claims have been paid against the provider within the previous year.
4. Providers removed from the lists maybe removed because TMA and ISOS decided the provider was a defrauder. While in the states there is an official list of providers found guilty of fraud that beneficiaries can use to avoid using them, TMA had decided to keep these charges and removals secret from the provider and beneficiaries; maybe because they are afraid of the consequences if providers find out.
5. A hospital listed as certified may not be certified for pharmacy but the list fails to mention that. If you use one of these hospitals all your pharmacy claims will be denied.
There is little defense against the poor quality of the list except to file complaints when it results in denial of benefits with TMA and Congress. For a more detailed explanation and how to defend yourself against these failures on the part of TMA and ISOS see Certified Provider Issues.
Care Provided Newborn Denied Due to Lack of DEERS Entry
We are seeing where ISOS is denying claims involving care provided at time of delivery on the basis that the newborn is not listed in DEERS and inquiries to their front Global 24 claim this is legitimate. However for more years than we care to count Newborn claims have been paid based on the DEERS entry of the mother and the contractors should, but apparently don’t, know that they have the ability to add a placeholder entry in DEERS for up to a year that would be used for claims processing of the newborn.
An additional issue is that given the current limited availability of appointments at the DEERS office at the Embassy a sponsor will have to wait 4+ months, best case, to get an appointment to add their new child to DEERS.
Anyone that finds ISOS denies their legitimate claim for care of their newborn should contact us for assistance.
Locally Purchased Items During an Inpatient Stay
For more than 7 years the claims contractor knew and understood that the local medical industry often requires patients to purchase expendable supplies and pharmaceuticals outside the hospital because they either don’t stock them or are out of stock. Since these represent costs associated with the hospital portion of the inpatient stay they should be included with the costs associated with the hospital’s itemized bill and paid IAW the CMAC inpatient per diem rates.
In the past when the claim was received and included these receipts and the dates on the receipts showed they were purchased during the inpatient stay they were automatically included. However with the advent of ISOS taking over the contract and the Demo it seems they have forgotten this common sense practice. As a result we are finding more claims where these purchases are being broken out into a separate claim and considered as outpatient care. This then causes ISOS to apply deductibles and copays and applied to each individual item which often results in underpayment of a legitimate claim.
Anyone that finds ISOS doing this should contact us so we can assist in getting the claim relooked and processed properly.
Ongoing and Longtime CMAC Issues
Recently and only after years of informing TMA of their failure to account for local inflation and exchange rate changes, they made a partial adjustment to the percentage used when they discount the U.S. CMAC for use here by going from 52% to 57%. While this tiny step after years of inaction is a step in the right direction, it does little to address increases of more than 30% since the CMAC was put into effect based on local inflation and lose of value to the dollar or corrects this problem where the CMAC is already at 100% of the U.S. rates.
The CMAC was a poorly designed quick fix that tried to find a simplistic method to convert the complex U.S. system of rates to a much simpler system in the Philippines. It was so poorly developed that they were required to make radical adjustments to their original percentages which more than doubled and quadrupled the original rates after we proved the original rates had no basis in reality. Even then they did it wrong. So now we have outpatient rates that are up to 5 times local rates while rates for surgical procedures are more than 50% below local rates.
Because of this poorly developed system local providers can defraud beneficiaries and taxpayers for outpatient services and now even have TMA’s blessing if they are Demo physicians. On the other hand beneficiaries find they are required to pay for the majority of the cost of surgical procedures while TMA claims what they paid is more than double local rates.
Another issue with this system is it now requires beneficiaries to convert local global bills, which are the local industry standard, to the complex U.S. billing standard. To do this a beneficiary must understand enough about medical terminology and procedures to come up with an itemized list of procedures their provider accomplished on them. Then they have to match those procedures against the unique U.S. medical coding system so they can use the derived codes to look up the CMAC rates for each procedure. This then allows them to distribute the global bill across all the individual U.S. billing standard procedures so they can file a claim. Based on actual claims data obtained via FOIA we found that only 7% of the billed amount for beneficiary filed claims for physician professional fees was allowed. That means that TMA only covered 75% of 7% of the actual bills leaving the beneficiary to pay the rest. See CHAMPUS Maximum Allowable Charge.
Please report your experiences and examples of over charges and claim denials to USMRoP
As we gather more information from TMA, the contractor and beneficiaries we will continue to send out newsletters but generally not more than once a month.
What we are seeing is rapidly put together policy that then changes within a few days only to be changed once 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 the experiment 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.
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