Tricare Philippines Newsletter 13001
Alert: Deliberate Overcharges under the Demonstration (Closed Network)
We believed this would happen long ago under this experiment and advised the TRICARE Management Activity (TMA) but they were not interested or concerned.
Local providers have been advised that they can/should double their charges under the experiment and have multiple reports of this happening. We believe this was done to entice them to join a network that requires they use a foreign billing system. These are the same tactics used in the past by HVC, at least one ISOS employee and others to increase profits and was claimed to be fraud by TMA; now that it is done under their program they sanction it claiming the CMAC is king. They even changed their policy to allow this. The policy used to say that providers were required to charge the same rates that they charge normal local patients but was removed from the manuals; now they can charge whatever they want. This was done, we believe, to protect their contractor from charges of fraud in the past; obviously they refused to address why they changed the policy which subjects the beneficiary and taxpayer to higher costs.
Under the CMAC the two top procedure codes paid by TMA are 99213 and 99214. 99213 has a maximum allowed charge of $40.16 (P1,647) and 99214 has a maximum allowed charge of $59.37 (P2,434). So any provider that charges any fee up to these amounts will be paid in full and you will be responsible for deductibles and copays.
In Angeles the local normal fee is generally P500 to P600 and already high compared to similar cities. Instead of paying a copay of P125 or P150 be prepared to pay as much as P608.
So far we have multiple reports to confirm this. At present the fees appear to have only doubled. So for a normal P500 visit beneficiaries are paying P1,000; copay P125 increases to P250.
If you do not have proof you paid your deductible such as an EOB or ISOS cannot confirm via their WPS account that you’re deductible was paid for the year you will be required to pay for the care in full up to your deductible amount. See our earlier warning on deductibles and how they are being mishandled; USMRoP Update Misinformation and Training on Deductibles by Global 24 aka ISOS.
The original provisions and one of the primary selling points that TMA toted to Congress, the VSOs and to beneficiaries to sell this mandatory program was that no deductibles or copays would be paid until the provider submitted a claim. However, at the last minute and under the claim beneficiaries requested the changed, that policy was changed to accommodate providers at the expense of beneficiaries; apparently being told they could double their fees and be paid was not enough. So now beneficiaries are required to pay deductibles and copays up front.
This leaves the beneficiary at the mercy of the providers who must file a claim in order for the beneficiary to get credit for the deductible they already paid. Until this happens there is no official record the deductible was paid. Since the provider has already been paid in full there is absolutely no incentive to file a claim and many reasons not to file a claim. Filing a claim will cost them money. Filing a claim will subject them to the same scrutiny beneficiary claims receive where many are denied for lack of information or amounts are disallowed for various reasons and many of you have firsthand experience with this. This would then cause the provider to lose some or all of what he has already gained. As long as the providers fail to file these claims and until TMA processes them the beneficiary will be required to pay the deductible over and over. In reality one could end up paying their deductible for the entire year, pay for the entire inflated outpatient visit fees for all their care, and never get credit for their deductible. In other words the beneficiary will have paid 100% of the cost of their care but at double the normal local fees or more. This doesn’t look like much of a bargain to us! But it will reduce the cost to TMA, by beneficiaries paying for all their care, and allow them to claim they have further reduced fraud in the Philippines by implementing this program. They will further claim they have greatly increased access to beneficiaries as well. TMA wins, the contractor wins, the providers win and the TRICARE beneficiaries in the Philippines lose once again.
While TMA knew this experiment was fraught with problems and being built on the fly by a contractor and/or employees that have at least been suspected of fraud in the past, they showed no concern for beneficiaries by making the program mandatory. The penalty for not using the program is you lose your benefit and the cost of care will not even be considered for cost sharing.
How do you protect yourself?
1 – Confirm the amount the provider intends to charge for the outpatient care if you use TRICARE and what they charge if you pay cash or belong to a local PPO before being seen.
2 – Consider paying the cash price, obtaining a receipt and filing your own claim and in particular if the TRICARE charge is more than the normal local charge for cash or local PPOs.
3 – Express your disapproval of the providers taking advantage of you and the American taxpayer.
Under this experiment we do have the right to pay cash, obtain a receipt and file our own claim. It will not only save you money, lower fees, but it becomes important if your deductibles have not been credited by TMA and by filing the claim you can get part of the money back and get credit towards your deductible. This same process should be used for all outpatient claims including laboratory, radiology etc. since it is likely they were told they could increase these as well. Be sure to insist the provider write on the receipt that the payment was for an “Outpatient Visit”.
4 – What to do for inpatient care.
There is no deductible for inpatient care including the hospital and professional fees. So your cost share will only be a copay of 25%.
However even here consider your options and ask what the rates are for cash/credit card or under TRICARE. If they increase the charges in this area as well your copay will increase also up to the CMAC. The CMAC will allow at least some of these overcharges for the hospital portion of the claim but as it is currently built it will disallow a significant portion of most professional fees, even the normal customary fees, and in particular surgical fees which are paid well below current local rates. So if the fees are inflated and you have the cash consider paying cash at the lower normal local rate for the hospital portion of the stay and pay your copay only for the professional fees and let them file a claim for the balance of the professional fees. You will have to file a claim for the hospital portion of the claim. (See our newsletter, How to File a Claim for the Hospital Portion of a Hospitalization) If the paid amount is less than the billed amount, likely, TMA should refund your overpayment to you and deduct it from what is owed the providers.
Consider writing you Senator or Congressman complaining about this program that increases your and the taxpayer cost and follows the examples of fraud that TMA accused us of in the past. Also consider contacting newspapers and other news outlets and let them know about this travesty.
Please report your experiences and examples of over charges to USMRoP
USMRoP Contact us at: US Military Retires of the Philippines
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 problem 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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