Tricare Philippines Newsletter 14005
Update on Ongoing Philippine TRICARE Issues
We deal with multiple issues with the unique and complex dual systems that the Defense Health Agency (DHA) officially calls TRICARE Standard in the Philippines. We are the only beneficiaries in the world who are forced to use a hodgepodge of two cobbled systems of care depending on the location of the provider or specialty involved.
With this convoluted system of care if one wants to see one of these specialists these are the current rules, as of 15 Jul 14, which apply. They are subject to change and are likely to change come 1 Aug 14 and again on 1 Sep 14 and into infinity.
This link will give you a larger view of the chart.
This convoluted and poorly documented dual system of care put together using U.S. health care industry standard processes for use in a foreign country beg questions on policy and quietly implemented 180 degree changes to past practices. Many of these policy changes cause beneficiaries to lose more access to care, pay higher fees and result in denied claims.
Because of this we have a long list of issues we address to DHA. DHA prefers to ignore many requests or take months or years to respond to questions on policy so the list continues to grow while beneficiaries continue to suffer under these policies and changes to policy that DHA refuses to address.
Below are a few of the issues we have addressed but have seen little or no movement. All of them can and do adversely affect beneficiaries through reduced access to care, higher costs, lower reimbursements and denied claims.
Requirement to Convert Local Global Bills to the Unique U.S. Itemized Billing Standard
This is the longest standing issue we addressed to DHA and the former TRICARE Management Activity (TMA). We first addressed this issue with TMA in 2008; a full 5 years ago. At the time we had discussions with a couple of employees about the issues involved. One agreed with our position and tried to take the concerns to senior management. The response was to tell him to stop talking to us. He failed to do that and was eventually removed from his position and forced to stop discussing TRICARE with any beneficiaries in the Philippines. His replacement informed us that he knew how to follow orders and refused to discuss Philippine TRICARE issues with any beneficiaries; this was a position responsible for overseeing TRICARE in the Philippines.
In another instance an individual agreed they may not have looked at some of the issues we addressed and said they would go back and relook the study they did that helped to drive this requirement. When TMA senior management discovered she was talking to us, she was forbidden from further discussion with us and I received an email from senior management instructing me not to try to contact her again. Another individual we’ve known for more than 35 years and who works at TMA was initially involved with the decisions that lead to many of the current restrictions on our access to care. When he voiced reservations to some of the restrictions he was summarily removed from participation from the process and those involved have refused to discuss TRICARE in the Philippines with him since.
Since those early days all of our attempts to address this issue have been ignored or we receive the party line that beneficiaries do not have to convert local global bills to the U.S. standard because all local physicians are apparently trained in the U.S. coding and billing system and will do it for us. International SOS (ISOS) continues to send letters out parroting this position. We and others have been told, in phone conversations with the claims contractor that if the physician can’t convert the global bill, to simply see their “claims processing” staff that will do it for us. These show a total and complete lack of understanding of local health care industry practices or a total disregard for the welfare for Philippine beneficiaries.
During this time we demonstrated
, using DHA’s own data, that beneficiary filed claims for inpatient professional fees that require the demanded conversion are almost always denied for a lack of this conversion. On average DHA allowed 7% of the billed amounts. The only conclusion a reasonable person can come to, if DHA’s claims are correct, is the beneficiaries prefer to have their claims denied rather than ask their physicians to convert the bill. To date DHA has consistently ignored all our inquiries that include this information. The same holds true of our inquiries using their own data that show reimbursement rates are at 13% of what would be expected when compared to the rest of the world.
When we tried to address this issue to our Senator and Congressman each were told by DHA that we essentially lied. They further went on to say that we think we are knowledgeable on TRICARE but know very little and provide wrong information which requires them to expend extra time and resources trying to overcome our bad information. This is a quote from just one of their responses on this subject.
“[He] sees himself as a TRICARE subject matter expert but the information he posts is incorrect. On several occasions, [he] posted misleading information regarding the requirement for TRICARE beneficiaries to code TRICARE claims, statements that he had not received any responses from TRICARE, and allegations that retirees residing in the Philippines have a “Separate but Unequal” health plan.”
The Philippines Demonstration was built on the assumption that local providers could convert local global bills to the U.S. unique standard. At the initial meeting in Manila on the Demo in October 2012, Frewen from ISOS, admitted that they had had no success in recruiting physicians because none of them knew how to convert their claims nor did they have staff that was trained in the U.S. coding and billing system. To overcome this he admitted they were limiting recruiting of physicians to those with offices at hospitals that would do the billings for the providers. This was a clear and unequivocal admission that physicians are not able to convert global bills as DHA has erroneously claimed for years. This approach didn’t work out well either as less than ten months into the experiment every provider in Angeles City, the single largest population of beneficiaries in the Philippines, quit the Demo and caught both ISOS and DHA with their pants down. For more than a week thousands of beneficiaries were left without a benefit as both ISOS and DHA remained silent; even inquires from Stars & Stripes went unanswered. Finally they responded to Stars & Stripes where they admitted providers were not able to convert claims and hired claims liaison officers to help providers with filing claims. Yet to this day, the largest single beneficiary population struggles under the Demo with a total of 36 part time physicians and a single hospital that most feel does not compare to other facilities that are now off limits to them and in violation of DHA’s policy on Patient Rights which says a beneficiary is entitled to a choice of providers. In addition the vast majority of specialties have waivers which require the beneficiary to revert to the limited Standard plan and file their own claim including converting their own claims.
We tried to follow-up with DHA now pointing out that they had proof, beyond a doubt, that our claims were founded in truth and they should now consider removing the requirement for beneficiaries to convert their claims or provide the same assistance as they are providing contractors with trained personal to help them file claims. As usual we were ignored.
While we were ignored DHA did make a half hearted attempt to address the issues of loss of access to care, increased cost and denied claims to the DODIG
. However they quickly backed down and let the DODIG dismiss their claims as unfounded. DHA told the DODIG, “The cost containment measures implemented in the Philippines and Panama were done as a result of findings of fraudulent billing practices in those two countries. Though these cost containment measures have dramatically reduced the TRICARE purchased care costs in those two countries, it has had a negative impact on TRICARE Standard beneficiaries’ access to quality health care and out-of-pocket expenses” and further “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 that TRICARE Standard beneficiaries seeking health care outside of 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 Philippine 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 go on to address a dramatic decrease in the number of claims filed and unique beneficiaries who filed claims in the Philippines. But what they failed to note, which is extremely important, is while claims decreased between 2009 and 2012 by 69% and beneficiaries filing claims by 52% the beneficiary population increased by 6.4% per the DOD Actuary. This only confirms the results of our survey that show that 77% of retirees no longer file claims because they know they will not be reimbursed. The other contentions contained in the DHA narrative further validate much of the other findings as well.
The sad part is the DODIG completely dismissed all of DHA’s allegations about the loss of access to care and increased cost to beneficiaries in the Philippines as undocumented and therefore unfounded. DHA failed to respond, letting the DODIG’s claims that there is no evidence of problems with access to care and increased cost to beneficiaries in the Philippines stand. This is an indication that while they are well aware of the multitude of issues that decrease access and increase cost to beneficiaries they don’t care enough to try to correct their mistakes or defend their position.
In the meantime beneficiaries continue to be told that local providers will convert their global bills and that they are not required to do so themselves.
See Like a Drug Addict, DHA is Still in Complete Denial When it Comes to Filing Claims! for our latest comments on this ongoing issue.
Overpayment of Demo Provider submitted claims in apparent violation of policy
In March 2013 it was brought to our attention that the claims contractor paid a claim for 7 laboratory tests as 7 visits and allowed the full amount billed by the Demo provider. The evidence provided was:
- The original receipt from the provider itemizing the 7 laboratory tests, the billed amount and the 25% copay paid.
- An EOB that showed these same 7 laboratory tests on the same day from the same provider. This EOB was denied as a duplicate but a second “duplicate” EOB was never processed or paid.
- An EOB that showed 7 other unspecified visits for the same total amount on the same day from the same provider but approved and paid as billed.
We prepared a letter asking for a clarification on the payment. If the claim had been paid using the actual tests accomplished and applied against the CMAC a significant portion of the billed amount would have been disallowed and the beneficiary would have received a refund on their copay. In the response we were simply told that the claim was properly paid. We then called and after some discussion were told that they had misinterpreted the TRICARE Operations Manual since 2008 and that claims for outpatient hospital services should be paid as billed charges. We pointed out that because of this many beneficiaries that submitted claims since 2008 had been underpaid due to this misinterpretation and shouldn’t beneficiaries be notified. We were told the contractor would go back and relook and reprocess all these claims.
While what was related to us may have been true, the method used to pay the claims still looked suspicious to us. In the past it was made abundantly clear that a claims processor violated the law and ethics standards if they changed the information such as procedures or medical codes that were submitted by a provider or beneficiary and they could not even interpret what the procedures were based on a narrative. This was the reasons given for why they could not use a doctor’s narrative summary to extract the procedures to process a claim from the Philippines. But in this example it was clear that they had changed 7 laboratory procedures to 7 unspecified visits using a CPT code that carried no CMAC rate as it was not normally allowed in the U.S. billing system.
So in July 2013 we asked DHA to confirm the policy change. In the following months we were given evidence of more ancillary tests over payments. For example a radiology procedure, CT-Scan, was paid as billed charges and at almost $400 over the CMAC. Again the procedure was changed from a CT-Scan to “other unspecified visit” by the contractor. Finally and after multiple follow-ups, in April 2014, we received a response that confirmed this change. We were also told since this was not really a policy change but due to a misinterpretation of policy there was no need to issue a statement addressing the change to beneficiaries because it really wasn’t a policy change. Further DHA’s feeling was during the 5 years this misinterpretation was applied to claims no claims were underpaid because of it and therefore there was no reason to have the contractor go back and review claims paid under the wrong policy, as interpretation.
We were in the process of gathering evidence to show that claims were underpaid when one of our own claims for lab work was processed and an amount disallowed as over the CMAC which was in direct contradiction to what the contractor told us and was subsequently confirmed by DHA. So we contacted the contractor by email and were told a “new” story. Now we were told the payment of outpatient procedures done by a hospital at billed charges did not apply to ancillary procedures done by the hospital. In other words it did not apply to laboratory and radiology and therefore did not apply to the claim in question. As you recall the original claim that brought this to light was for laboratory procedures and paid as billed charges as was the radiology CT-Scan and both to Demo providers.
So we went back in May 2014 to DHA asking why the contractor changed the policy they confirmed as valid just weeks before. Even after multiple follow-up inquiries all we have is silence from DHA although we know they received our inquiries.
At present the policy that billed charges are paid for outpatient care provided by a hospital, including ancillary services, seems to only apply to claims submitted by Demonstration providers and not to beneficiary submitted claims. DHA has no plans to publicize the change nor will they comment on the about face made by the contractor and see no reason to go back and reprocess prior claims that were underpaid due to this mistake.
No Need to Use Certified or Approved Providers in Many Cases
As with everything dealing with the unique complex dual systems called TRICARE Standard in the Philippines let the buyer beware. As in the issue above, policies can change overnight and without notice to beneficiaries and then change back again within hours or change to yet another version.
In March 2014 I was advised by my ophthalmologist to see a retina specialist as soon as possible because he suspected a possible detached retina. I was in Manila at the time and therefore under the experiment (Demo) rules. As with the majority of specialties, retina specialists are not available as a Demo Approved provider; there is also no blanket waiver. While there was a certified one in the area, he was not available. So I decided to see the one recommended by my ophthalmologist. As it turned out I had a small hole in my retina that could have resulted in a detached retina. The specialist recommended a laser treatment to tack the retina in place around the hole; I agreed. I paid for the visit and was scheduled for the treatment a few hours later at the hospitals eye center. After the treatment the doctor told me I could return to his clinic and pay his clerk or pay the hospital cashier. Since his office was in another building I opted to pay at the hospital cashier and he gave me a document with his name on it and the amount. The cashier accepted the document and money and provided a receipt showing the physician as the provider of care and the amount charged and paid.
Knowing I needed a waiver and that ISOS had failed to comply with their contract and issue a blanket waiver I returned home and completed and filed a waiver request. A few days later the waiver was approved and I faxed my two claims to Wisconsin Physician’s Service (WPS). Within days the claim for the much more expensive procedure was approved and paid while shortly after that the visit claim was denied on the basis the provider was not an approved demonstration provider.
With both claims I included a copy of the approved waiver and a statement that the provider was not certified but said he was willing to be certified. So I expected both claims to be held up for 90+ days waiting for ISOS to get around to certifying him. Yet the expensive procedure was approved and paid without question while the visit was denied. Confused yet? I was.
First I appealed the denial and pointed out I had a waiver and had in fact included a copy. WPS relented, requested the provider be certified and later reprocessed and paid the claim. While most beneficiaries would not question a full payment of a claim, I’m a masochist so I questioned why they paid a claim for a provider that was neither certified nor approved. The response from WPS was that they were not concerned with who provided the care but what provider appeared on the top or letterhead of the bill. So while the bill and receipt clearly showed the physician as the provider of care and recipient of the payment, WPS was only concerned with the letterhead information. If they were certified then it mattered not who or what the real provider was.
I questioned this approach with DHA and was informed that WPS claimed this was the standard but they offered no opinion on the apparent violation of the requirement that providers had to be certified or approved before reimbursement could be made. So I questioned the practice again and pointed out that under this standard we could use any provider without regard to certification or approved status for inpatient care or as long as we paid the provider through a certified or approved provider. I also pointed out that under the revised Bureau of Internal Revenue (BIR) rules hospitals are required to list and collect all physician professional fees for inpatient care. Between the WPS standard and the BIR rule this means any provider that provides care during an episode of inpatient care at a certified or approved hospital will be paid without question.
So far DHA has remained silent on the issue. To add to the complexity of this issue I saw a physician that was not certified but who had a clinic at Chong Hua Hospital in Cebu City. The bill and receipt letterhead showed the physicians name, clinic location and Chong Hua as part of the address. Fully expecting to see this claim held for 90+ days pending certification I was again surprised that it was paid without question and under the certification of Chong Hua hospital.
What this implies is that as long as the physician has a clinic at a certified hospital all claims for care from the physician will be honored without regard to the physician’s certification or approved status. We added this new policy to our question to DHA about the policy of using certified and approved providers. As usual we are still waiting for a response.
Some may question why we are questioning claims paid and say “Don’t look a gift horse in the mouth”. While these unpublished policies have benefited me personally, they are unpublished and in conflict with published DHA policy. We pursued this because the contractor could change their process in minutes and DHA could demand beneficiaries reimbursement them for the errors and omissions of their contractor. Four months into this and, as usual, we are still waiting on DHA to respond.
We have many more issues which we are and have been pursuing with DHA. The ones above are some of the current major issues we felt you should be aware of.
Bottom line. DHA is well aware that their policies and practices have seriously impacted access to care and increased the cost of care to beneficiaries in the Philippines as is demonstrated by their comments to the DODIG. But at the same time they prefer to ignore the suffering and pain their policies and practices have imposed on beneficiaries in the Philippines while they continue business as usual. This should send a clear message to every beneficiary that this group of bureaucrats is far more interested in keeping their jobs and future promotions than in providing a legitimate and fair medical benefit to TRICARE beneficiaries in the Philippines.
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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