U.S. Military Retirees of the Philippines Group

Tricare Philippines Newsletter 15003

Some Observations from Reviewing and Investigating Errors and Other Anomalies on the Approved and Certified Lists
 
For almost two years, since July 2013, we have been monitoring the ‘fake’ certified and approved lists we are forced to use as they were published on the web. Initially we did this on the 1st and 15th of each month. Once International SOS (ISOS) stopped publishing lists we continued by pulling all the certified, approved and not seen in > 2 years providers from the ISOS database on the 1st of each month.

Here is what we found:

 
Loss of Ability to Prove a Provider Was Listed on the ‘Fake’ Lists

Over the last twenty-two months we have come across multiple examples where a provider was listed on one of the ‘Fake’ lists but not listed on the Official list that ISOS and Wisconsin Physician Services (WPS) use to approve payment of claims. In a conversation with WPS customer support we were told they come across providers listed on the ‘Fake’ lists but who are not on the Official lists all the time. This forces them to hold the claim and request certification of the provider. If the provider declines certification, a common occurrence, then the claim will also be denied. Without proof that ISOS screwed up the ‘Fake’ list the beneficiary has no other recourse except to eat the cost of their care. We know ISOS will not admit to any mistakes so asking them to substantiate the mistake would be a waste of time. With proof the beneficiary could demand that the claim be paid as he followed the rules and could enlist the assistance of his congressman or senator. We asked the Defense Health Agency (DHA) to implement a policy that when this scenario occurs the claims contractor would be required to pay the claim as if the provider was certified. As usual we have not received a response and we suspect, if they ever respond, they will claim that ISOS assured them that this almost never happens so there is no need for such a policy as not enough beneficiaries will be penalized to make it worth their while.

Part of what we do each month is to maintain a complete list of providers who were listed as certified or approved as of the first of each month and have that information back for more than two years. So, in spite of ISOS and DHA, if one of you ever needs to prove a provider was listed at a given time we maintain that information. Feel free to contact us at
U.S. Military Retirees of the Philippines and, unlike ISOS and DHA, we will be glad to assist.
 
“Not Used in > 2 Years” List No Longer Maintained
 
Almost two years ago when we started this exercise we discovered that the providers removed from the certified list were never added to the Not Used in > 2 Years list. At that time there was 339 providers on the list. If one looks at the January 2013 list, six months earlier, they will find 699 providers on the list. In the almost two years we have maintained these lists and check providers removed from the certified list against the Not Used in > 2 Years not one provider has been added; not one! As of 1 May 2015 the list has a grand total of eight (8) providers remaining.

This is what ISOS has to say about the listing of
providers.

“Always check the status of certification for any provider from whom you may seek care, even if that provider has previously appeared in these listings. These listing are frequently updated and some providers/institutions may either:

Be removed for unspecified reasons,
request their own removal,
fail to be re-certified or
be removed to an inactive status for not being used by a beneficiary in two years.”


If one can believe this rhetoric from ISOS then one has to assume that in almost two years not one provider on the certified list ever reached a point where they were not seen in two years making them eligible to be moved to that list. One can also assume ISOS simply forgot or screwed up and left them on the certified list in violation of their own claims and there is some evidence of this which we will address later.

We have been trying to address this issue with DHA for over a year. At first we were asked to provide proof that providers were not being added to the list which we did in aces, since then silence.

Either way it is clear beneficiaries cannot trust anything they are told by ISOS.

 
Manila and the Growing Number of Certified Providers
 
The infamous TRICARE Demonstration Project for the Philippines, also called the Demo got off to a very rocky start in January 2013. At this point it has been in various stages of operation for almost two and a half years. Under the claimed rules TRICARE beneficiaries that reside in the Philippines are required to use only Demo providers, known as ‘approved’ providers in the limited locations where the Demo is in effect. The geographic areas are Angeles, Olongapo, Metro Manila, Cavite and Iloilo.

The exceptions to using approved providers were when a waiver was received or a blanket waiver was available because there were no approved providers within the specialty. Most areas have significant blanket waivers with the exception of Metro Manila which has few by comparison. Another exception is TRICARE beneficiaries that were traveling in the Philippines. The Demo does not apply to Prime Remote beneficiaries who have their own set of providers.

Consider the following:
  1. ISOS claims to remove all providers that have not been used in two or more years from the Certified list and moves them to the Not Used in > 2 Years list.
  2. The Demonstration has been in effect for almost two and a half years.
  3. Certified providers cannot routinely be used within the Metro Manila area without a waiver.
We found a strange anomaly in the Certified list dealing with certified providers in the Metro Manila area. So we went back and counted the number of Metro Manila certified providers on the list as of January 2013. We found there were 1,583 providers. Next we counted the number of certified providers on the list as of 1 May 2015. We found there were 1,823 plus an additional 200 approved providers who are also certified for a total of 2,023 providers. Since the start of the Demonstration the number of certified providers in Metro Manila has increased by a whopping 440.

Considering that the vast majority of TRICARE beneficiaries cannot use these providers this is extremely puzzling. The natural assumption would be that there would be almost no need to add more certified providers in an area where the vast majority of beneficiaries cannot use them. Another assumption would be that the majority of the original 1,583 would have reached the point in time, during the last two and a half years where they were eligible for transferred to the ‘Not Used in > 2 Years’ list. If these certified providers are valid then there were at least 1,823 visits, one for each certified provider on the list during the last two years. Given the low number of visits, based on claims filed, shown in a recent DODIG report this seems to be almost impossible.

There are only two conclusions we can come to. The first is that ISOS has screwed up again and failed to move any providers in the Metro Manila area to the ‘Not Used in > 2 Years’ list during this time. Given that we documented that not one provider was moved to that list in almost two years this conclusion seems to be the most logical; ISOS has failed to properly manage the provider lists. The recent findings by the DODIG and DCIS showing massive failures in the past by ISOS in managing the lists and DHA’s failure to inspect their contractor add additional credence to this conclusion. The second conclusion is a very large number of beneficiaries visited the Metro Manila area on a continuous basis, think tens of thousands, in order to continue to utilize not only the original number of 1,583 but to cause it to increase to 2,023.

What conclusion would you come to?

 
Approved Providers Have No Relationship to Beneficiary Populations
 
DHA and ISOS don’t have a clue where the TRICARE beneficiary population lives in the Philippines and apparently don’t understand how to use their own data to approximate the population location. If you can believe their claims the vast majority of beneficiaries live within the Manila, Cavite, Angeles and Olongapo area with a small pocket living in Iloilo leaving two to three hundred living in the other 98% of the Philippines. While we also don’t have precise numbers we do know that the largest single population is located in Angeles City followed by Metro-Manila, Olongapo and Cavite but they do not comprise more than about 60% of the total population. We find DHA’s claim that Iloilo has the fifth largest population questionable based on historical information. But for this discussion we will concede that Iloilo has the fifth largest population of beneficiaries.

If we assume these figures are correct and those living in these areas are required to use only approved providers unless a special waiver is approved, then we would also expect that the numbers of approved providers and hospitals by area to reflect a similar relationship so as to assure adequate access to care. In other words, the largest number of approved providers and hospitals would be in Angeles City while the fewest would be in Iloilo.

Let’s look at the actual numbers based on the approved provider list as of 1 May 2015. As you can see the location with the largest population has, by far, the fewest providers and a single hospital. The reason for this is clear if you have followed the Demo failures. Less than a year into this experiment every approved provider in Angeles quit in-mass and without official notice which caught both DHA and ISOS with their pants down. In fact for more than a week beneficiaries in the area were totally without access to care and neither DHA nor ISOS would respond to inquiries; not even from
Stars & Stripes.
 

If we were to believe these numbers then we would have to believe that Angeles City has very few beneficiaries with Metro-Manila having the most followed by Cavite and then Iloilo.

But wait! DHA claims that there are almost no beneficiaries outside these Demo areas. That means there are almost none in Baguio, La Union, Cebu, Tacloban, CDO or Davao. In fact DHA told
Air Force Times there was no hurry in offering assistance to beneficiaries after Typhoon Haiyan because the central Philippines had virtually no beneficiaries. To quote from the article:

“Tricare spokesman Austin Camacho could not say exactly how many beneficiaries live in the area affected by the typhoon, but Tricare has received roughly 50 medical claims from the area in the past two years.”

Let’s look at this claim from DHA for a minute, fifty (50) claims from the central Philippines in two years. That translates into twenty-five (25) claims a year from the following provinces. Masbate, Northern Samar, Samar, Eastern Samar, Leyte, Southern Leyte, Aklan, Capiz, Antique, Negros Occidental, Negros Oriental, Bohol, Guimaras and Iloilo. Yes even the province of Iloilo where Iloilo City resides and DHA, in a conflicting claim, says contains the fifth largest population of beneficiaries in the Philippines and of sufficient size to warrant millions of dollars to be spent to bring the Demo there.

Iloilo City has a total of 98 approved providers to handle that large beneficiary population of beneficiaries. In addition there are 153 certified providers in Iloilo City, 3 of which are hospitals.

Let’s assume for a minute that DHA made a mistake, not hard to do, and the 50 claims did not include Iloilo but came from the rest of the central Philippines. In fact let’s take it one step further and assume all the 50 claims came from the Metro-Cebu area only. Let’s also assume that every claim represents at least 3 different providers that are never duplicated. In other words the 50 claims were filed by beneficiaries living or receiving care in Metro-Cebu and represent 150 encounters with 150 unique providers over a two year period. Is that a stretch, you betcha, but bear with us. Go back to the chart above. The Metro-Cebu area has 201 certified providers including 10 hospitals. If all the 50 claims were from this area and each claim represented 3 encounters with different unique provides over a two year period how could there be 201 certified providers in the area; 51 of them would not have been used in more than two years and therefore should not be on the certified list. So why are these providers who haven’t been used in more than two years still on the certified list?

What this really shows is just how bad a handle DHA and ISOS have on TRICARE beneficiaries in the Philippines including where they are located and where they are when they receive care. To maintain certification on this number of providers one could expect that more than a five hundred (500) claims would have to be filed every year in just the Metro-Cebu area; so much for their published claim in Air Force Times.

Keep this in mind the next time DHA or ISOS make some claim about the multiple TRICARE programs in the Philippines.

 
DHA and ISOS Manipulate the Demo Rules in an Attempt to Keep it From Going Under
 
You may have also noticed one hospital listed under “Hospitals Illegally Approved” for Olongapo. DHA and ISOS were unable to recruit a decent hospital in the Olongapo area to participate within the Demo area which falls within the geographic boundaries of Olongapo City. So they went outside the city to recruit another hospital; one that tends to overcharge on the advice of ISOS. While DHA and ISOS can violate the rules of the Demo a beneficiary that violates the rules is punished by non-payment of claims. They tried this in Angeles as well but so far they have not found anyone foolish enough to agree. Again these acts make it hard to believe anything one is told by DHA or ISOS.

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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