Tricare Philippines Newsletter 14003
Update on Issues and Changes to the Philippine Dual System of TRICARE
In this issue we will try to address some ongoing issues and changes to policy that the Defense Health Agency (DHA) and International SOS (ISOS) feel do not need to be made available to beneficiaries in the Philippines. This appears to be local policy rather than worldwide policy. For example DHA announced that service centers were to be closed at military facilities and over a two month period we received at least 20 notices and reminders from DHA. Given their apparent guidelines on publicizing policy changes for Philippine beneficiaries we would have been lucky to have seen even one notice.
Certification Process and Cebu Hospitals
We have been working for more than a year trying to get to the bottom of why Cebu Doctor’s Hospital, in March of 2013, and then Chong Hua Hospital, in December 2013, were removed from the Certified Provider List. Providers are removed for three reasons; 1) they refuse to have anything to do with ISOS, a growing problem, 2) they have not had a TRICARE claim filed for care provided by them in three years or 3) ISOS determines they are not a legitimate provider or were suspected of fraud and declared secretly sanctioned.
ISOS does not want you to know why, how or what they do with your benefit and invoke various false claims of secrecy or proprietary privilege to keep you in the dark. In most cases these claims are bogus but they depend on you not taking them to court and spending money to get an answer you have every right to have; it works to keep you in your place and allows them to do pretty much as they please. In the case of certification they claim they and their local administrative clerks are immune from discussing certification in accordance with 10 USC 1102. 10 USC 1102 concerns the protection of medical quality assurance records. However per the DODIG they state, “According to the [ISOS] contract, the non-network provider certifications include confirming the existence of a physical building through onsite reviews, verifying the credentials of the facility or provider, assessing the adequacy and capability of the facility or provider for providing patient care, and ensuring that the credentials conform to the requirements of the Philippine government and its licensing boards.” The National Center for Biotechnology Information defines quality assurance as, “Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.” Confirming the physical existence of a provider and verifying their credentials against the Philippine licensing boards doesn’t qualify as “quality assurance” information. That leaves “assessing the adequacy and capability of the facility or provider for providing patient care”. The DODIG qualified this process as [recording] “various items to be observed in medical facilities such as medical equipment, number of staff, and patient volume”. This also doesn’t qualify as “quality assurance records”. Further medical quality assurance is carried out by highly trained physicians and nurses, not local administrative clerks looking for fraud and checking boxes on a form.
After much effort by our group, including Congressional inquiries, it appears we have succeeded in getting Chong Hua Hospital back on the Certified Provider List and it should appear on the 15 April 2014 list. (For anyone that used this facility while it was classified as an illegitimate hospital and had a claim denied you can now request reconsideration and the claim should be paid.)
We have not been so lucky with Cebu Doctor’s Hospital. We were successful in fighting the initial sanction for suspected fraud by providing the Philippine law that required the action they were sanctioned for. However ISOS Program Integrity, the proponent for certification, does not accept the Philippine government’s licensing standards and have added additional requirements. If a hospital does not or will not jump through the additional hoops they are removed and sanctioned as an illegitimate hospital. It appears this is the current status. So while they are accredited by a U.K. based clinic and hospital accreditation organization, licensed by the Philippine government, accepted by the U.S. Embassy and is accepted by hundreds of real insurance companies worldwide, TRICARE patients are not allowed to use this facility simply due to a bureaucratic paperwork exercise that has nothing to do with the validity of the hospital and certainly nothing to do with the quality of care or quality assurance. To add insult to injury and demonstrate how unrealistic the ISOS process is, they have certified 3 or 5 subordinate hospitals owned or affiliated with Cebu Doctor’s Hospital; talk about a dichotomy.
We can only wonder how the Philippine government and people will feel about the U.S. government claiming their ability to license hospitals is questionable and requires the U.S. government to go behind them and second guess their policies and actions. This is probably the reason they keep these sanctions secret from beneficiaries unlike listing them for everyone to see everywhere else in the world.
Billed Charges Now Sometimes Apply in the Philippines
We have been working this issue for more than a year also and for most of that year we could not get a definitive answer from DHA. But finally we have an answer although at present all indications are DHA doesn’t feel the need to advertise this change; instead calling it a misinterpretation of policy that has been corrected and therefore not a change in policy.
Early into the Demo we discovered many claims filed by Demo hospitals were being paid in full without regard to the CMAC rates which if they had been applied about 25% of the billed charges would have been denied which would have also reduced the copay by 25%. We did an appeal to one of these to WPS indicating it appeared to be in error. The written response failed to provide specifics but said the claim was processed and paid IAW current DHA policy. Later we were able to obtain more specific feedback.
The references cited in that feedback were the TRICARE Reimbursement Manual 6010.58-M, Chapter 1, Section 34 and Section 35 para 4.1.1. These references discuss how hospital and physician claims are to be paid in the Philippines, in essence mandating the use of the CMAC designed for U.S. billing practices. If you read through all of this what is missing are references to non-inpatient hospital claims. Non-inpatient claims from a hospital would be for a full range of outpatient services including laboratory, radiology, chemo therapy, physical therapy, ambulatory surgery, nuclear medicine, etc. Note, these same bills from a private lab etc. are not covered by this exception and will still be paid under the CMAC designed for U.S. billing practices which is inconsistent but the Dual TRICARE Benefit system in the Philippines is built on inconsistencies.
This technicality allows the payment of billed charges for both provider and beneficiary filed claims. Further, since this is not a change to the manual but a change based on what would be called a previous misinterpretation, all claims that were underpaid since the implementation of the U.S. designed CMAC, some six years ago, should be reviewed and the denied amounts cost shared. While it appeared Wisconsin Physician’s Service (WPS) was inclined to do this it also appears that DHA would just as soon look the other way. We requested that these claims be reprocessed but have not received an answer and are not confident DHA will do the right thing.
We also requested that DHA issue a notice on this change but the feedback we got was, since it is not a change to policy, there is no need for a notice. We appealed this claiming while policy may not have changed, how it is applied has.
However a beneficiary can request that any claim previously filed be reconsidered based on new information and in particular those within the previous 3 years. We recommend you review any old EOBs and take this action if appropriate. Further everyone should check their current claims closely to insure they are processed correctly as we are finding examples where WPS still inappropriately applies the CMAC and assisted with one that was appealed where the difference was then paid.
Acceptable Double Proof of Payment
Recently we were assisting with a claim and WPS demanded the infamous “Double Proof of Payment” and emailed a list of acceptable items that could be used. The list was significantly different from what we had seen before.
The following is the full list of approved proof of payments provided by them:
1. Credit card statement or credit card receipts.
2. Beneficiary's bank statement documenting the dispersal of funds with provider name. Cash withdrawal on a bank statement must have one of 3, 5, or 6 attached.
3. “Paid” stamp with provider name and date of payment on a claim, receipt, itemized bills, or a statement (stamp has to be on every page summary or total page).
4. Copy of the check showing the service provider’s name in the “Pay to the order of” field and signed by patient or sponsor.
5. Electronic Funds Transfer (EFT) transmission with the provider’s name (if not directly to the provider, one of: 3, 4 or 6 are required).
6. Provider’s itemized bill statement and (provider’s) matching official receipt signed by the cashier or check number. “Matching” means that the same (dollar) amount and official receipt or check number must be on both documents.
Further discussion reveled with item 2 they expected bank statements to show the name of the provider associated with the withdrawal or cash withdrawals in exact amounts when compared with items 3, 5 or 6. Item 6 requires both the itemized bill and receipt include references to the receipt number and both letterheads match; possible but not likely in the Philippines.
We asked about ATM receipts and loan statements and were told to refer to the “official list” previously provided.
After months of discussion we were told that ISOS would provide further guidance to WPS and include information that allows ATM receipts and loan statements and that the withdraw amounts from banks do not have to match dollar for dollar with each receipt but that we may be asked to explain which withdraw(s) went to pay which bill. We have no way of knowing if ISOS will follow through with this promise as we have multiple examples where they promised DHA they would do something and never did.
If anyone encounters issues with the “Double Proof of Payment” requirement please contact us.
Secret Lens Purchase Agreement
The Demonstration was developed in a vacuum by bureaucrats in Washington with no experience with the Philippine health care industry standards and refused input from local military retirees, some with years of experience in health care administration and the local standards. Then they turned lose a contractor with little or no supervision. The predictable and inevitable occurred; secret agreements between the contractor and providers, unanticipated consequences due to lack of knowledge of the local industry and more.
Some of these we already know about and previously reported:
The latest exposed agreement requires beneficiaries to purchase the lens used during cataract removal surgery. This secret agreement was first exposed when a beneficiary tried to obtain assistance from the ISOS front Global24 (G24). As is common practice G24 made no attempt to resolve the issue and the beneficiary had to pay for the lens. It was reported to DHA and he was assured that G24 staff and all ophthalmologists were retrained and lenses were covered under the Demo. Seven months later the same thing happened again and once again G24 ignored the beneficiaries request for assistance. The beneficiary asked the facility why he was required to pay for the lens and was told that G24 had instructed them that it was up to the doctor if he wanted to participate on the lens or require the beneficiary to pay for the lens. This was reported to DHA who ignored the complaint about G24’s lack of assistance but claimed that ISOS would talk to the providers involved and denied G24 told providers they could decide if they participated on the lens; implying the providers made it up. Our investigation of this claim showed that, as expected, the ISOS claim was weak as providers at other hospitals claimed they were told the same thing by G24. A follow-up with the original hospital and doctor to see if G24 had corrected the claimed misinformation resulted in our being told that yes ISOS had talked to them but agreed they could still decide to participate or not on lenses and pointed out they had just done another surgery under the Demo and the beneficiary was required to pay for the lens. Another follow-up with DHA resulted in a comment that G24 was now admitting to the secret agreement and it was required or these doctors would resign from the program.
- Instructed providers that they could/should increase fees by 2 to 4 fold such as visit fees.
- Agree to allow providers to collect deductibles at time of care without considering local industry standards and no requirement that they submit claims.
- Completely unaware of local standards where hospitals require inpatients to purchase from outside sources many items required in the provision of their care.
- Allowed some hospitals to refuse care to beneficiaries after hours and tried to hide it from both beneficiaries and DHA.
- Unaware of local industry standards of care where local insurance plans provide private rooms and where semi-ward conditions constitute semi-private rooms forcing beneficiaries to suffer ward like conditions or pay for their own rooms under the Demo.
- Made no provisions for beneficiaries with PhilHealth so many were refused care under the Demo.
Our suggestion passed to ISOS that they post a notice on their webpage and provide handouts on this policy to the doctors to give to beneficiaries to explain the exception, including lenses covered and how to file a claim but it was ignored. We then passed the suggestion to DHA who is taking our suggestion under advisement but there has been no commitment that beneficiaries will be told of this secret agreement. In the meantime beneficiaries will continue to be told to believe the DHA and ISOS hype; “You will not have to file claims for medical care received by an Approved Provider. Approved demonstration providers have agreed to file claims on your behalf.”
One of the insidious consequences of this secret policy is beneficiaries may find they are not reimbursed for lenses the ophthalmologists recommends and some ophthalmologists push higher priced lenses because they add a percentage to the actual cost. Because ISOS is unaware of this they have made no provisions for it. The policy manual only allows a lens that restores vision. They generally do not pay for those that also correct previous vision deficiencies which can increase the cost 4 fold. ISOS failed to train Demo providers in these rules, IAW the TOM Chap 18 Sec 12 para 4.2.7 so they have no clue and one of the reasons we suggested a handout. Disregard the comment in the manual that states “Lenses must be FDA approved” as that does not apply under the TRICARE Overseas Program. However many ophthalmologists offer them and we recommend their use if available.
Use of Non Certified or Approved Providers and without Waivers Okay Under Some Circumstances
The jury is still out on this as it violates multiple provisions of the TRICARE Operations Manual so be careful, but this policy has been in place for at least a year. We recently addressed this WPS policy to DHA and the policy was confirmed but they may decide to reverse it. And as happens much of the time these changes to the Dual Philippine TRICARE Benefit are done in secret to the detriment of beneficiaries; they call it cost avoidance in the fight against beneficiary fraud.
A beneficiary recently had to undergo an emergency ambulatory procedure at a Demo hospital. There were no approved providers so a non certified or approved provider was used and the providers billed amount was paid through the hospital cashier. The beneficiary then requested a waiver which was approved and submitted the claim which was paid within 5 days without question. Surprised, the beneficiary called WPS who explained that what physician provided care was not important; only the provider name on the letterhead of the receipt which would always be considered as the actual provider of care. This policy applies under either Standard or the Demo.
In essence as long as the policy stands and as long as the receipt reflects a certified hospital, or approved in Demo areas, you can use any provider of your choice. Also because DHA considers the care provided by the hospital and not a physician and if it is outpatient care, the provisions of, “Billed Charges Now Apply in the Philippines”, as outlined above apply which means for surgical procedures, which are grossly underpaid by the CMAC, will be cost shared in full. It appears this policy also applies to inpatient professional fees as well as long as the receipt for those providers is from the hospital.
However, as with all policies that affect the Dual TRICARE Benefit system in the Philippines, they are subject to change without notice. If we find this or any other policy changes we will immediately post the change to the TRICARE Overseas Philippines Blog
TRICARE Plus Removes you from the Demonstration
In a recent development a retiree took his family to Guam and because of many issues he had with the Demo and sought care at the local military hospital (MTF). The hospital enrolled him and his family in TRICARE Plus. While the TRICARE webpage claims that this does not affect your TRICARE Standard benefit and only offers primary care at the MTF, G24 refused to allow the family to use the Demo on return unless they disenrolled from TRICARE Plus. An inquiry to DHA confirmed that G24 was correct in their refusal since they think the family does not reside in the Philippines. So it appears, if you prefer not to be saddled with the Demo limitations on access to care and chose your own providers even within a Demo area simply go to Guam and use the MTF and get enrolled in TRICARE Plus.
Limited Access to Care under the Demo
TRICARE’s published Patient Rights states, “As a patient in the Military Health System, you have the right to: Your choice of health care providers”. In many instances ISOS has recruited only one provider in a specialty but chose to ignore TRICARE policy and force us to use a single provider. In one instance, not only was only one provider made available they provider only offered 4 hours of clinic in the Demo area and no inpatient coverage because they lived 50+ miles away. This violation was brought to DHA’s attention and they directed ISOS to recruit more providers or request waivers. So they have been digging at the bottom of the physician barrel to recruit providers who are not certified because no beneficiary previously wanted to see them, quality issues come to mind, to get them to sign up. In addition several areas still lack two providers but DHA seems to feel as long as ISOS claims they are still searching for a warm body willing to sign up, that meets the standard of our right of choice of health care providers. We suggest, if you need to see a provider and there is only one and you don’t trust that provider, you should request a waiver under the provisions of TRICARE’s Patient Rights
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
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