Tricare Philippines Newsletter 14007
The Demo Survey, Billed Charges, DHA on Access to Care & ISOS Customer Support
The Demonstration Survey; How it Really Worked
I’m sure many of you read the various messages from the Defense Health Agency (DHA) regarding what they called a survey. The initial notice was dated 14 March 2014. Among the various claims DHA said;
“Would you like a chance to tell us what you think about the Philippine Demonstration Project?”
“If you received care at any time during 2013 in Metro Manila, Angeles City, Pampanga; and Olongapo City or Zambales, you may be contacted soon and asked to complete a survey. To be contacted for the survey, your information must be current in the Defense Enrollment and Eligibility System (DEERS). Please update your information, especially your telephone number and e-mail address in DEERS.”
Beyond the obvious implication that DHA doesn’t know where the Demo took place, the invitation sounded inviting and appeared to offered a chance to be heard by DHA; something that almost never happens. However after months of waiting nobody was contacted. Our inquiry into this resulted in our being told that DHA forgot to comply with a DOD directive on surveys dealing with privacy so the survey was on hold. We also pointed out the obvious errors in the listing of areas where the Demo occurred. Finally on 31 July 2014 another notice came out. In it they said;
“If you received care during under the Philippines Demo during 2013, we want to hear from you!”
“The Defense Health Agency is partnering with Zogby Analytics to conduct an official satisfaction survey. The survey will ask your opinions about the care you’ve received in the Philippines. Zogby Analytics will contact you if you lived in or received care in Manila, Angeles City, Pampanga, Olongapo City or Zambales any time during 2013.”
Beyond the obvious errors to the Demo locations they again hosed, the new promise was in essence that all beneficiaries who lived in or received care in Manila, Angeles City, Pampanga, Olongapo City or Zambales would be contacted. We confirmed that they would try to contact everyone.
However after weeks passed and almost nobody was contacted we again inquired about the survey. To make a long story short, over a number of months we were told that what they said was not true. The published statement, “Zogby Analytics will contact you if you lived in or received care in Manila, Angeles City, Pampanga, Olongapo City or Zambales any time during 2013.” Was a completely false claim. As it turned out living in or receiving care in Metro Manila, Angeles City or Olongapo City was not the real criteria after all. Instead the real criteria was designed to eliminate almost all beneficiaries that received care in these areas during 2013 and it did.
What was the real criteria? Based on what we were told, if one or more of the following apply the beneficiary did not receive care in a Demo area.
We would like to elaborate on the use of Reason Code 292. Reason Code 292 states, “Services provided by an Approved Demonstration Provider.” This code did not come into existence until almost half way through 2013, thereby automatically eliminating all care received to that point as being consider under the Demo. Further we have evidence that the majority of claims during the rest of 2013 and even those in 2014 do not contain this magic reason code. One thing we discovered is the claims processor’s automated system does not allow more than one reason code per line so if any other reason code is assigned by the claim processor reason code 292 will automatically be removed. We informed DHA of this but were ignored.
- If you were seen but the provider failed to file a claim, very common for those that paid in full due to their deductible, you were not considered as having received care under the Demo.
- If you chose to annotate the claim form asking that your EOB and checks be sent to your FPO address, a process that was approved by DHA, you were not considered as having received care under the Demo.
- If you tried to avoid the massive fee increases directed by International SOS (ISOS) by paying cash at the customary local rates and submitted your own claim, you were not considered as having received care under the Demo.
- If you received care in the Demo areas but have since changed status such as moving back to the states, you were not considered as having received care under the Demo.
- If when your claim was processed and the claims processor failed to include Reason Code 292 on your EOB, you were not considered as having received care under the Demo.
Multiple attempts to prove that care was received by a beneficiary by providing multiple EOBs that clearly showed the provider as part of the Demo even though an FPO address was used and even in one instance where a local address was used but Reason Code 292 was missing proved futile. We can only conclude they were not interested in capturing real input but only interested in making a show of capturing real data.
The Analytics Division of the Defense Health Cost Assessment and Program Evaluation office and Senior Program Analyst Kimberley A. Marshall, Ph.D. were responsible for this survey and whatever results may come from it. However, as with most surveys, the actual survey questions and results will never be released; probably considered top secret. Nor will the statistical analysis that justifies the accuracy of the results. For one to do this they need to know the actual population survived and they have absolutely no viable data to show the number of beneficiaries that reside in the Demo areas or how many came from outside the areas to seek care. Instead we will be expected to believe whatever generalizations these people put out. In essence it is likely the results will be self-serving.
Almost two years ago we discovered that Demo providers were being paid billed charges for hospital based outpatient care and at rates significantly above the CMAC in many cases. One example was a CT scan that was paid at four times the CMAC rate. We inquired of Wisconsin Physician Services (WPS) about this and was told it was discovered that they misinterpreted TRICARE policy and had been paying these claims improperly since 2009. We were also told that this change would apply to beneficiary submitted claims for care in the Philippines. We attempted to confirm this with DHA and after almost a year and multiple requests received a confirmation that this was true. We suggested the publish this change and were informed DHA didn’t consider it a change and not worth informing beneficiaries. We asked if they were going to go back and reprocess old claims that were underpaid and were told it was not necessary. (If you have such a claim that was underpaid, it may be worth your while to quote this change and request the claim be relooked.)
Shortly after this we discovered a beneficiary claim for hospital ancillary work that was paid under the CMAC and tried to point out the error to WPS. We were informed by WPS that the new policy did not apply to ancillary services; a reversal of their prior stand. So once again we went back to DHA asking for clarification since they had just informed us the new policy did apply to ancillary care. As I’m sure you guessed, it took multiple inquiries and another year to obtain a confirmation that what we were originally told was true and WPS was wrong.
Bottom line, if you file a claim for outpatient services provided by a certified hospital WPS should allow the full amount billed without regard for the CMAC. If they fail to do that you should remind them of the new policy.
The Defense Health Agency's Admission that there are Significant Access to Care and Increased Cost Issues with the Philippine TRICARE System
In April 2014 the DODIG issued an audit of overseas health care, DODIG-2014-052. Contained within that audit is a clear admission by DHA that there are serious problems with access to care and increased costs to TRICARE beneficiaries in the Philippines.
The following quotes from DHA in the audit say it all. “Though these cost containment measures have dramatically reduced the TRICARE purchased care costs in those two countries [Philippines & Panama], it has had a negative impact on TRICARE Standard beneficiaries’ access to quality health care and out-of-pocket expenses. Evidence of this is that in Panama there are inpatient facilities refusing to see any TRICARE Standard beneficiary because our reimbursement rates do not cover the cost of care provided. TRICARE Standard beneficiaries in the Philippines also complain that either they cannot access quality health care because of the low TRICARE reimbursement rates or that their out-of-pocket expenses are exceptionally higher than TRICARE Standard beneficiaries seeking health care outside the Philippines. As we implement the Philippine Demonstration Project, we are finding many providers in that country are unwilling to participate because of the terms of the demonstration. Not only are we requiring them to accept the TRICARE Philippines Foreign Fee Schedule and not charge TRICARE beneficiaries any additional fees, but we are also requiring them to submit the claim on behalf of the beneficiary. Providers have been reluctant to accept these constraints, which has limited access for some of our beneficiaries.” They further admitted to the DODIG, “The DoD does not have a large permanent presence (assigned ADSMs and ADFMs) in Panama and the Philippines, and TRICARE pays billed charges for health care provided to those ADSMs and ADFMs.” If the CMACs are so accurate why does DHA prefer to be defrauded by providers when treating ADSMs and ADFMs?
Included with these admissions are a simple chart showing the number claims filed and the number of beneficiaries that actually filed claims. Another chart lists TRICARE expenditures. However, as usual, DHA failed to go far enough with this information and the DODIG poo pooed the claims as unsubstantiated.
We took the liberty of doing the work DHA should have done by adding some additional information to the chart.
The payment, claims and unique beneficiary numbers are from the audit charts. Beneficiary population was extracted from DOD Actuary reports for each of the years listed. The balance of the information is simple calculations using this data. What is noteworthy is the CMAC was implemented at the start of FY 2009 which included the requirement that beneficiaries submit itemized claims that met U.S. billing standards. The direct result of this requirement and the inability of beneficiaries to comply with this requirement are graphically reflected in the percentage of beneficiaries that filed claims by year. Within four years DHA was successful in reducing the number of beneficiaries that participated in TRICARE in the Philippines to 37.5%.
Note that in FY2012 the percentage of beneficiaries that filed claims was 37.5%. Remember the data used to calculate these figures are official information published by the DODIG, DHA and the DOD Actuary. If you look at the DOD Actuary Philippine population you will note that more than 55% of the military retirees and survivors are 65 or over. This population utilizes health care at a much higher rate that a younger population. But let’s just consider the average number of visits and discharges for 2010 as shown by the CDC for the entire U.S. population; the latest data we could find. They state, Discharges per 10,000 Americans are 1,139.6. The 2012 population is greater than 10,000 so we would expect to see at least 1,139 discharges in this population. They state that a population of 10,000 would be expected to visit a doctor 40,820 times a year. This doesn’t consider the tens of thousands of prescriptions, laboratory and radiology encounters that would also result from those 40,820 visits. Yet only 37.5% of the beneficiary population even bothered to file a claim and they averaged 4.94 claims each. The other 62.5% of the beneficiary population apparently received no care; no hospitalizations, no visits, no laboratory or radiology work and no medications, absolutely none.
While the DODIG claim there is no evidence, we submit that there is overwhelming evidence that what DHA has done in the Philippines is at the very least immoral if not criminal. When less than 4 out of 10 beneficiaries obtain care and where the majority of the population is near of above 65 years of age there is no defense for what they have done. When you also consider that the per capita expenditure in the Philippines for FY 2013 is less than 7% of what is spent on every other beneficiary, even after adjusting for the claimed lower cost in the Philippines there is absolutely no doubt that what is going on is immoral if not criminal.
What is troubling about this is how DHA is two-faced when it comes to these admissions. Recently DHA claimed that the Philippines Demonstration Project is now perceived to be running well, as is the general TRICARE Program in areas outside of the Demonstration locations. So it appears they admit their failures to the DODIG when trying to defend other actions but to our face they claim just the opposite. How can anyone believe anything they are told by people like this? DHA gets away with this because we are overseas, out of sight, out of mind. They would not dare treat beneficiaries in the U.S. like this.
ISOS Customer Support
Anyone that uses ISOS and customer support together obviously has never experienced what they palm off as customer support. In other words ISOS and Customer Support are mutually exclusive terms. When we discuss ISOS we are including their front Global 24. We have dozens of examples of the lies put out by ISOS or as is more common beneficiaries that call are told the ISOS employee has no idea how to answer the question but promises a call back within the day. But in almost all cases no call back ever happens. Personally we are still waiting on promised calls back from February 2014. The same goes for emails. Beneficiaries may receive an automated response claiming that someone is working on their issue but a real response never comes. If the beneficiary emails a follow-up asking for the status of the response, it is generally ignored. We have dozens of examples of this.
More recently we found the ISOS influence has also degraded WPS customer service. Some recent examples. We were told that Chong Hua hospital was not shown as certified on the official list although shown on the “Fake” list we are required to use. Later another employee said that was a mistake. We were told that ISOS had assured DHA that a claim that was wrongly denied due to non-certification was being reprocessed. Weeks after this claim by ISOS the beneficiary called WPS and was told not only was the claim not being reprocessed but that no claim where the patient was seen prior to the date of the most recent certification would ever be paid. (Obviously this is a complete and total misrepresentation of the truth and a follow-up call confirmed that the original individual apparently does not understand the TRICARE program in the Philippines.)
In another case a claim for inpatient professional fees was denied for failure of the beneficiary to obtain prior authorization. The primary diagnosis was Dengue with a secondary diagnosis of seizure resulting in admission from the emergency room. A call to WPS confirmed that the claim had been wrongly denied and the beneficiary was promised that the claim would be reprocessed and a note that it should not be denied for prior authorization added to the claim file. A week later the claim was denied again for the same reason. Another call to WPS confirmed that once again the claim was wrongly denied and again promises were made that it would be done right the next time. The beneficiary asked to speak to a supervisor and was called two days later. He explained what happened and asked that the supervisor insure that this time the claim be processed properly and was assured it would be taken care of. Two weeks later the new claim was still pending so the beneficiary called to ask what the hold up was and was told they would expedite the claim. Two days later that claim was denied. You guessed it, denied for failure to obtain prior authorization. Another call was placed to WPS who again acknowledged that it was denied in error and another promise made to do it right the 4th time around. As we write this we are waiting to see if ISOS and their employees can get it right on the 4th try or if once again it is denied. Now the claim for almost $1,000 has been in limbo for 45 days since received by WPS. So the beneficiary has been denied the use of his funds for at least 45 days. Anyone care to place bets of if it gets processed correctly the 4th time?
Are you getting any sense of the crap beneficiaries are forced to endure under ISOS and their subcontractors? You are only seeing the tip of the iceberg. Most beneficiaries simply give up since they have absolutely no alternatives. And this is proven is spades by the information above that shows only 37.5% of beneficiaries used TRICARE in 2012. We know that figure dropped considerably in 2013 but don’t the DHA data to prove it.
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.
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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