Tricare Philippines Newsletter 13010
Provider Certification; The Secret Paperwork Exercise Gone Bad
Certification of providers has become the second most insidious tool developed by International SOS (ISOS) and sponsored by the Defense Health Agency (DHA) to defraud beneficiaries out of access to care and the rightful payment of the cost of their care.
The DODIG states the purpose of certification is to “ensure that "certified" medical providers actually exist and that beneficiaries always receive medical care from licensed medical professionals at accredited facilities.” Let’s see how that has worked out for Philippine Standard beneficiaries.
About 13 years ago DHA, formally TRICARE Management Activity (TMA), responded to some fraudulent claims by implementing a process to confirm providers listed on claims were actual, legitimate and licensed providers. With no research or understanding of the local health care industry they contracted with International SOS to create a system to validate providers when claims were filed. Being a company in the business of making money they bypassed the obvious and cheaper methods of validating providers in favor of one that required travel, expensive hotels, rental cars, personal interviews and more; all of which allowed for billing opportunities.
The system got off to a rocky start because TMA failed to fully inform beneficiaries of this new requirement. The list of Certified Providers also proved not to be a true list at all but a mix of unrelated names of providers who were not certified. See a History of the Certified List. Claims were denied with a curt statement, THE PROVIDER IS NOT TRICARE CERTIFIED. No explanation as to what “Certification” meant or how a provider could be certified was offered. The most criminal part of all was the total failure on the part of TMA to inform the beneficiary that, while their claim was denied, ISOS was out certifying the provider and if they were certified the beneficiary could request the claim be reconsidered and paid based on the new certification. During the first six years TMA saved millions by keeping this a secret from beneficiaries and claimed to Congress the saving came from their anti-fraud measures but was really on the backs of beneficiaries.
Since the entire process was unmonitored, it wasn’t long before ISOS and/or its employees discovered that they could certify just about anything they wanted without regard for meeting any standards as they were never audited, see DODIG Report No. D-2011-107. It wasn’t long before we saw doctor’s offices consisting of two rooms certified as tertiary hospitals with wards, operating rooms, labs and x-ray departments, emergency rooms and ambulances all housed in those two rooms. Amazingly these same doctors discovered they could file fake claims as a hospital and be paid tens of thousands of dollars without question; one can only wonder how they discovered they could do that. Then it wasn’t long before we found businessmen in two small rooms certified as physician groups with as many as 15 or more doctors; all presumably occupying those two small rooms. For a detailed explanation of these see, How the process of certification of doctors as hospitals and businessmen as physician groups came to light.
We are constantly told by DHA and ISOS the process of certification is “secret” and/or “proprietary” for years and for no real apparent reason other than they want to provide as little information as possible to beneficiaries about their restricted Philippine TRICARE benefit. This secrecy doesn’t apply to beneficiaries in the States or other countries.
We found this on the internet concerning Why does the government keep secrets from the people? The answer - To protect their agenda.
That seems to apply for both excuses, proprietary and secret. Both DHA and ISOS have an agenda that underlies this process and they don’t want those that are affected and impacted by that agenda to know what it is. We do know the dollars from legitimate claims that are denied due to these secrets are claimed as saving by their fraud program and presented to Congress as such; could that be the agenda.
As much as they have tried to protect their agenda however, we have discovered much of the process. Some new information comes from the DODIG who apparently don’t see the process as protected as secret or proprietary; maybe they don’t have an agenda.
See our previous newsletter Current Understanding of the Provider Certification Process for a comprehensive discussion of the process and how to protect yourself as much as possible.
However, as seems to be the normal process, when DHA and ISOS are found negligent in the performance of their duties, as shown in DODIG Report No. D-2011-107, the typical response is to punish Philippine beneficiaries by further reducing access to care. Recent actions on their part that have recently come to light clearly show this.
When ISOS developed the process, as would be expected, they built a system to increase their revenue by bypassing the Philippine system of provider certification and reinventing their own more expensive process. All local health insurance plans recognize the Philippine licensing process as do overseas health insurance plans from virtually any country including the U.S.; companies such as U.S. civil service Blue Cross and Blue Shield, GEHA Benefit Plan Nationwide and many others. Only TRICARE finds it necessary to add multiple additional administrative layers over local licensing but none that consider the quality of care and ignore the reality that the provider is legitimate and already licensed by the government.
We don’t know which specific additional requirements DHA offered up to be added to the certification process in an attempt to make amends for their historical failure to monitor the process. But we can offer some likely possibilities. These come to mind, Barangay business clearance, Community tax certificate, Municipal engineer clearance, Zoning certification, Fire safety permit, Mayor’s permit, Business permit, Registration certificate from DTI, proof of quarterly tax payments to BIR, proof that SS and PhilHealth payments are made on each hospital employee and others.
Because of recent events where legitimate and licensed providers simply disappeared from the Certified list we investigated these removals. Over the last 6 months more than 150 providers have secretly been removed. While some may be removed for legitimate reasons such as a physician died or retired or a provider closes their business we are aware of a significant number of the providers who are still in business and operate under the rules of the Philippine government and are legitimate providers.
Of note is Chong Hua Hospital in Cebu, one of only four internationally accredited hospitals in the Philippines and arguably the best facility in Cebu, which was removed from the list. In addition Cebu Doctor’s University Hospital has also gone missing and DHA and ISOS have grown mute as usual. Both facilities are still in operation and recognized as legitimate facilities by the Philippine government and all major insurance companies except TRICARE. This is a clear indication that the secret paperwork exercise or process has become more important than the original purpose as stated by the DODIG which says the purpose of certification is to “ensure that "certified" medical providers actually exist and that beneficiaries always receive medical care from licensed medical professionals at accredited facilities.” In essence these providers and probably many more have been removed and/or sanctioned in secret. Sanctioning of providers occurs when they are found guilty of wrong doing such as failure to provide the additional data or fraud.
In the states providers that have been convicted of fraud against Medicare or TRICARE are sanctioned by not allowing them to participate or be paid by medical insurance companies. Once they are convicted they are placed on one of two sanctioned lists which are available on the internet. The more extensive of these lists can be found on the U.S. Dept of Health & Human Services. This list contains only the names of those that are currently sanctioned and contains 55,864 names mostly from the states but around 100 from overseas. Of those overseas only one is from the Philippines. The TRICARE Sanctions list appears to contain every provider ever officially sanctioned by DHA as the sanction has expired on a great number of them. This list contains 110 names. All of them are from the U.S. except 18 which are from the Philippines. Of the 18 only 8 have currently active sanctions.
But that’s not the end of the story. We know of many Philippine providers who have been removed from the Certified list and apparently tried and convicted of fraud in absentia. DHA apparently found it more convenient and expedient to bypass legal action in favor of their current secret process which puts beneficiaries in jeopardy. We became aware of this process years ago. Initially they posted a list of these providers on the TAO-P webpage, Providers Excluded from TRICARE. But within a few months it disappeared. We asked that it be reactivated but were told that DHA was afraid of possible adverse actions against them if the providers became aware they were sanctioned without due process, so refused. So for the last five years the identities of these secretly sanctioned providers have been kept secret from beneficiaries unlike in the states where they have access to the information. If a beneficiary is unaware of the sanction and uses one of these providers their claims will be denied out of hand but they will not be told the truth about why the claim was denied. Only in the Philippines does DHA keep the process secret.
Some indications you are being “had” by the DHA are when you see the claim denied because the provider is not certified and the denial comes within two or three weeks of receipt by the claims contractor. If you inquire as to the reason the provider was not certified you maybe told the provider “died”, “closed their office” or “retired” on some date before the date(s) of care or it is just a “secret”. Since you saw the provider you would obviously know most of this it false information. Another indicator is, while anyone that submitted bills and receipts for care from a non-existent provider would be investigated for fraud, they will not pursue fraud charges as they know they would be found out and their secrets exposed. There are thousands of examples of this.
While some of these providers may have been involved in fraud, like the physicians that ISOS certified as tertiary hospitals so they could file false inpatient claims, we know of others that did nothing wrong and the basis for the claim of fraud was based on local policy or law which local providers have no control over. In essence, because of these secret convictions and sanctions DHA is forcing beneficiaries to play Russian roulette whenever they have to see a provider that is not currently certified.
It is obvious that DHA has made a conscious decision to discriminate against Philippine beneficiaries once again, further reducing access to care. In order to try to reduce the adverse impact of this treatment we are producing and updating a list of providers removed by ISOS and DHA under suspicious circumstances. We recommend all beneficiaries use this list before seeing a non-certified provider. If they need to see one on the list question them as to why ISOS removed them and indicate it might have been because of claims of fraud on the part of DHA. Follow the use instructions found on the front sheet of the list. You can access the list at this link, List of Secretly Removed Certified Providers. The list will be updated as ISOS posts a new list and a notice will be placed on our Blog. The list is in Excel format to allow sorting.
It is time we stand up and put a stop to this discrimination. When you find yourself in a situation where a claim is denied under the circumstances outlined above. Or you see a provider you use and know is still legitimate is removed contact ISOS by email and ask why the provider was removed from the Certified list; TRICARETSN.TOP@internationalsos.com . Based on our experience and feedback from many others, ISOS will most likely ignore your email or will respond with a comment they will look into the issue and then never respond again. If you call you are likely to be told they will call or email you with an answer but it won’t happen. That is why we recommend using email so you have a record of how you were treated.
Use your email and this newsletter and complain to your Congressman about how you are discriminated against by DHA and ISOS and how they refuse to respond to legitimate questions that affect your access to care. Point out beneficiaries in the U.S. and other countries have access to lists of providers removed for cause but you are denied similar access. Also mention that DHA will likely claim massive fraud in the Philippines forces them to do everything in secret but that much of the fraud happens in DHA’s own back yard which they have failed to notice and again cite this newsletter. It is time we stood up to be counted.
If enough beneficiaries provide us feedback on the sanctioned providers, such as they are still in business or retired or were sanctioned because the provider refused to cooperate etc., we will add an additional sheet to the list of sanctioned providers with this information. Please contact us with this information at, firstname.lastname@example.org
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.
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