U.S. Military Retirees of the Philippines Group

Tricare Philippines Newsletter 14002

Update on issues with Philippine TRICARE plans plus possible progress on resolving some issues
 
In this issue we will explore a number of issues, with work-a-rounds in some cases and actions you can take to try to force change. We will also address some possible improvements in the future.
 
Patient Rights
 
The Defense Health Agency (DHA) likes to claim that Philippine beneficiaries use
TRICARE Standard Overseas. One of the toted benefits is, “With TOP Standard, you manage your own health care and may generally seek care from any host nation provider without a referral.” In the Philippines that claim has been significantly limited for many years by local DHA policy and International SOS’s (ISOS) inability to certify providers. With the implementation of the mandatory but limited Demo, local DHA policy completely removed this benefit in Demo areas. DHA also claims in their TRICARE Patient Rights, “As a patient in the Military Health System, you have the right to: Your choice of health care providers”. A recent blog article covered this in more detail.
 
To have a choice one must have the ability to choose between two or more providers but in a large number of specialties, Demo areas offer one provider and in some cases this provider offers as few as 4 hours of clinic per week for both local and Demo patients which is a clear violation of this policy. We addressed this issue to ISOS and their front Global 24 on more than one occasion but they chose to ignore our emails as well as this violation of patient rights. We addressed this issue to DHA early into the Demo and were also ignored. However a recent study we did that included the extremely limited clinic hours of these single providers seems to have gotten DHA’s attention and indications are ISOS will be required to add waivers for any specialty that offers just a single provider. If this occurs it will significantly increase access to care in Demo areas where our rights were violated for more than a year.


Missing Local Employee
 
DHA promised beneficiaries and the DODIG that they would place a
DHA employee in the Philippines. But years later there is still no employee and they ignore inquiries. A local employee can be important to getting a better benefit in the Philippines as they will see firsthand the issues with the contractor and their adversarial interaction with beneficiaries and providers. They will be able to observe the real and actual roadblocks to access to care caused by poor policies and learn the local health care industry standards and processes which will allow them to see how TRICARE, certification and the CMAC disconnect with local health care standards of practice. This should cause them to become our advocate with senior management to affect change.
 
Recently we were asked to assist with preparing a question to pass to the Director of the DHA, Lt. Gen. Robb, when in a hearing before the Military Personnel Subcommittee of the Congressional Armed Services Committee. Congressman Barber, AZ 2nd District, is a member of the Armed Services Committee and has shown concern for our plight and wanted to pose a question surrounding the situation here. The question addressed issues with the adversarial relationship between the contractor, beneficiaries and providers, a lack of responsive customer support, issues with certification such as Chong Hua Hospital in Cebu. Then it asked the status of placing the promised position in the Philippines and suggesting it would be prudent to take immediate action on this position to help mitigate these issues to finally improve access to care. Congressman Barber is waiting for a response from Lt. Gen. Robb.
 
We encourage everyone to contact Congressman Barber and let him know they appreciate his support, regardless of where you vote. Our hope is he will get a response that indicates when the employee will be in place in Manila so we all can pass our issues and concerns to them like DHA assured the DODIG would happen.


ISOS Data Disclaimer and Ongoing Data Issues
 
International SOS (ISOS) has for years forced beneficiaries to endure
substandard information on certified providers and now approved providers including duplicate providers, misspelled provider names, wrong addresses or cities and much more. DHA has shown no real interest in cleaning this up saying instead that the information is “adequate for Philippine beneficiaries”.
 
Now ISOS has added a twist to their bad data. They now have a
disclaimer that proclaims they accept no responsibility for any harm caused by their failures.
 
“International SOS and its subcontractors have made reasonable efforts to ensure that the list of Providers displayed is up to date and accurate at the time of printing. Please call the Provider before making an appointment to verify that the Provider continues to see TRICARE beneficiaries and is certified or approved.” and “Neither International SOS nor its subcontractors shall be liable for any losses, damages, or uncovered charges as a result of using this Philippine Demonstration Approved/Certified Provider locator Website print function or receiving care from a Provider listed in this Website/report without prior verification, as described above.”
 
Let’s examine this requirement where we are now required to personally verify that a provider is approved or certified with the provider himself. It shows that ISOS is well aware the information it provides to beneficiaries carries a high probability of being in error and they are correct in that assessment. It also shows that DHA doesn’t care if the contractor provides viable services or not.
 
If we fail to verify the published information is correct and a claim is denied because the listed provider is not certified or approved or has a wrong name or is in the wrong city we lose. We personally know that many of the part time clerks who work for these doctors at their part time clinics have no idea what approved, certified or TRICARE mean and none have copies of any documents to prove certification or approval. So the only way to verify for sure is to visit the doctor, which will result in a visit charge, and ask to see copies of the documents they signed that caused them to be certified or approved. If they have them on hand and if they agree to show them to us we then have to try to make a judgment call as to whether they are still valid or expired and that the provider was not removed for some secret cause since the list was published which is happening all the time now. (One has to be careful as well since we know of cases where providers told beneficiaries that they were certified but had been removed years before.)
 
Once accomplished the question then is how will we prove we met this requirement to protect ourselves? Remember ISOS claims no responsibility for the validity of any of the data and have charged you with verifying it. If you find your claim denied because of the bogus data ISOS is paid to publish you will have to prove you met this requirement. The obvious answer is to require the provider to sign a declaration that he allowed you to examine his credentials and he meets all certification and approved provider requirements and his status is current and in good standing as far as he knows and then have his signature notarized. Without this one has to assume they have failed to meet the requirements to confirm a provider is certified/approved as they will have no proof.

Providers Declared Illegitimate or Fake
 
The
provider certification process is broken. Per the DODIG Report No. D-2011-107, Improvements Needed in Procedures for Certifying Medical Providers and Processing and Paying Medical Claims in the Philippines, TRICARE implemented the Philippines Certification Program in the Philippines to confirm the existence of a physical building, verify the credentials of the facility or provider, document the medical equipment, number of staff and patient volume to show ability to provide care and ensure that credentials conform to the requirements of the Philippine government licensing boards. The audit found ISOS negligent in performing this task with almost half of inspected certifications incomplete; lacking key documents, such as current medical licenses or completed inspection forms or both. Further they found that DHA (TMA) had failed to develop mandated internal controls to monitor the contractor performance even after being previously chastised for the same failure years earlier.
 
Because of these repeated failures on the part of ISOS and DHA we may now be seeing passive aggressive behavior exhibited by both parties with regard to current certifications resulting in inappropriate denials and denial of access to care for beneficiaries.
 
In January 2013 Cebu Doctor’s University Hospital disappeared from the Certified Provider List. In September 2013 Chong Hua Hospital also disappeared from the Certified Provider List. A hospital in northern Luzon disappeared along with many physicians and other hospitals and all without explanation. Inquires to ISOS indicate these hospitals do not meet the requirements above but they refuse to discuss them, claiming the information is secret and try to hide behind 10 USC 1102.
10 USC 1102 concerns the protection of medical quality assurance records. The U.S. Code, under definitions says, The term “medical quality assurance program” means any peer review activity carried out before, on, or after November 14, 1986 by or for the Department of Defense to assess the quality of medical care, including activities conducted by individuals, military medical or dental treatment facility committees, or other review bodies responsible for quality assurance, credentials, infection control, patient care assessment (including treatment procedures, blood, drugs, and therapeutics), medical records, health resources management review and identification and prevention of medical or dental incidents and risks.
 
Nowhere does it include “administrative” tasks such as confirming the existence of a building or office, confirming the existence of credentials such as federal licenses to practice or operate a hospital or in some cases business permits for physicians or documenting the existence of medical equipment, staff and patient volume. Clearly none of this information can be construed as a peer review involving quality of care, doctor’s credentials, infection control, assessment of patient care or reviews or processes to identify and prevent medical incidents and risks. So this claim is just one more ruse used by ISOS and DHA to hide their mismanagement and failures from those that suffer the consequences.  
 
Let’s examine just one of these secret removals, Chong Hua Hospital.
 
  1. Physical building: It is a 666 bed hospital in a multistory building that can be seen from a great distance.
  2. Federal License to operate a hospital: Licensed by the Philippine Dept of Health, approved by PhilHealth (requires basic quality standards), member in good standing, Philippine Hospital Association, certified by Philippine Council for Quality Assurance in Clinical Laboratories, and accredited by the Joint Commission International (JCI).
  3. Does it have medical equipment, staff and capacity: This should also be self evident considering it meets PhilHealth standards and is 1 of only 4 hospitals in the Philippines to meet the quality standards required to be accredited by the JCI. When compared with many certified hospitals, including some that are Demo approved, it is even more evident these are not an issue.
 
It becomes obvious this facility is licensed, exists and far exceeds the standards of the vast majority of facilities that are presently certified. It also demonstrates how little concern DHA has for the quality of care and well being of TRICARE beneficiaries in the Philippines as this single act has eliminated the single internationally accredited hospital available to the southern half of the Philippines denying access to quality care for thousands. But ISOS and DHA have declared that these hospitals either do not exist, are illegal, defrauders, unlicensed by the government or all of the above; otherwise they would be on the certified list.
 
Everyone should be outraged at these arbitrary and secret removals and contact local newspapers, Stars and Stripes, U.S. newspapers and Congress to let them know how you are outraged that you are denied access to quality care and treated as
Second Class TRICARE beneficiaries by the well paid contractor and DHA.

Why File Claims and Issues with Demo Providers Demanding Payment in Full
 
Why File a Claim?
 
As you all know and as demonstrated in our
military retiree survey, the majority of beneficiaries pay for their own care and don’t file claims and we found many in Demo areas who prefer to use their own, quality, providers so pay for their care as well. DHA uses claims data to determine where beneficiaries live by assuming they live in the same vicinity as the provider. Since most do not file claims the claims that DHA uses came, for the most part, from businesses certified as physician groups or physicians certified as hospitals whose intent was to overbill TRICARE. Most of these were located in Angeles, Olongapo, Manila, Cavite and Iloilo based on the ISOS database provided to us with data from the first 7 years of certification.
 
So it comes as no surprise that they claim that the vast majority of beneficiaries live in these areas and why they saw no value in providing
timely relief to typhoon Hiayan victims. At the time DHA claimed across the entire center region of the Philippines effected by typhoon Hiayan they had only received a total of fifty (50) claims in the previous two years an indication that maybe 10 to 15 beneficiaries live in Samar, Leyte, Cebu, Negros Occidental, Iloilo, Capiz, Aklan and Palawan combined. There are no accurate methods to determine our population distribution so some proxy needs to be used, although there are better ones than claims. Even if you know your claims will be denied because you cannot break out the medical procedures, code and then cost them, at least you will be counted as existing by DHA. Previous newsletters have provided the basic requirements, outpatient requirements and pharmacy requirements for filing claims. If you follow the guidance most of these claims should also be paid. And DHA will know you exist if you just file one claim per beneficiary per year.
 
Provider revolt while the contractor looks the other way
 
We have recently seen indications that approved Demo providers are demanding payment in full or refusing to provide care. One instance involved a physician that
refused to treat a retiree as an inpatient at AUFMC unless they agreed to sign a statement that they would pay him in full at time of discharge. Another involved a physician that required a beneficiary to pay for the lens used in cataract surgery at TMC and even after he emailed and complained to Global 24 who ignored his complaint and failed to follow through and address the issue to the provider. So two days later he was required to pay for the lens. This act appeared to be deliberate in order to inflict harm to the beneficiary as no attempt was made to contact the beneficiary or provider, even weeks later. It is clear ISOS and Global 24 are negligent in properly managing the Demo.
 
We believe providers are revolting against ISOS, DHA and the Demo because of poor training and non-payment or under-payment of claims. As we have pointed out multiple times before, a viable medical plan must be fair to beneficiaries and providers alike. The Demo is unfair to both; providers are not paid and beneficiaries lose credit for deductibles, pay higher copays and have extremely limited access to care and are forced to pay in full for care while ISOS looks the other way. The only winner is ISOS who makes money on the backs of the providers and beneficiaries and DHA who continues to save money by denying and underpaying claims while maintaining massive fraud continues to plague them.
 
Multiple Demo hospitals have advised beneficiaries that they have no intention of filing claims when the full cost of the care is covered by deductibles or in one instance only after all of “their” claims are filed. Because of this we continue to recommend that those forced to use the Demo protect themselves by paying for visits and outpatient ancillary care where the full cost is covered by the patient’s deductible. This will allow you to then file a claim and get credit towards your deductible and has the added advantage of obtaining the care at local rates instead of the much
higher TRICARE rates that ISOS told providers they should charge. See the links above on how to file these claims.

DEERS Registration Moved Overseas
 
On 29 January 2014 the embassy announced, and with no advance warning, that the DEERS office was closed until further notice. This means no ID cards and no registration of wives and children into DEERS which means they are not eligible for TRICARE. The embassy tried to place the blame on the Defense Manpower Data Center (DMDC) by claiming they are responsible for local staffing. We confirmed with DMDC that is absolutely not true and staffing is the responsibility of the local embassy which also refused assistance from the RAO in Manila before closing the office. Since then they have been silent on the issue and may be hoping we will all forget that we once had a DEERS office. This appears to be a deliberate act by the embassy to remove our ability to access DEERS registration and we suspect was intended to be permanent from the start. We understand that Army retirees can go through the Angeles RAO to register family members and obtain ID cards but it can take months. All others have no local options so will have to fly to Guam or Thailand to register their family members. Thailand has a much more retired military friendly embassy and DEERS access is offered three mornings a week by walk-in. We recommend retirees write their congressman about this arbitrary decision by the embassy.

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.

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