Tricare Philippines Newsletter 13008
Cautions with TRICARE at the Start of the New Fiscal Year
While much of this has been brought to your attention in various forms in the past we thought it best to bring all these issues together in one place. That’s because these issues can cost beneficiaries large sums of money if they are not aware of them and know the work-a-rounds; The TRICARE Management Activity (TMA) and International SOS (ISOS) will not warn you of these traps.
Deductibles under the Demonstration
In conjunction with the start of each fiscal year your annual deductibles start over.
Under the Demo most outpatient care paid in full due to deductibles will never be submitted as a claim by approved providers. This will cause beneficiaries to pay the deductible multiple times and still not obtain credit. So never use the Demo process when the cost of the care is covered by your deductible.
How do we know this is true?
Many beneficiaries reported that encounters as far back as January 2013 where they paid the full amount due to their deductibles have never been processed and they never got credit.
ISOS refuses to discuss any requirements placed on Demo providers that require they file these claims other than claiming the information is none of our business and is proprietary.
Two hospitals have told retirees that they see no value in filing these claims as they will receive nothing in return.
Increased cost of care under the Demonstration
Demonstration providers have been advised by ISOS and their front Global 24 that they can and should disregard local customary fees in favor of charging at the CMAC rates. In particular we see this for outpatient visits were local customary fees of P450 to P600 have increased in excess of P2,000 or between 2 to 5 times the local customary fees charged other patients, including those that have local medical insurance plans that many times obtain discounts.
How do we know this is true?
Anyone that has used the Demo for outpatient care has seen these price increases.
Multiple retirees have been advised by hospital staff, supervisors and doctors that they were told by “TRICARE” [ISOS/Global 24] to increase their fees for TRICARE patients.
How do you protect yourself from the many negative attributes of this mandated plan you are forced to use?
The simple answer is to pay cash for all outpatient procedures and demand you be treated the same as all patients IAW Republic Act No. 7394 – THE CONSUMER ACT OF THE PHILIPPINES, Title III, Chapter I, Article 52, Paragraph b. that protects consumers against prices that grossly exceed the price of similar services in similar transactions by like consumers. We know of at least one Demo provider who demands double payments even for cash if he thinks you are TRICARE so cite this law or use someone else; do not buy into the fraud.
By paying cash and filing your own claims for outpatient care you insure you get credit for paid deductibles and obtain the same care at less than half the price that the TMA and ISOS designed Demo demands. In addition you won’t find you are required to pay your deductible two or three times over. Filing outpatient claims are simple if you follow a few basic rules. If you are not familiar with filing outpatient claims, previous newsletters have been devoted to the process.
Newsletters you should read
Basic Claim Filing Rules for the Philippines provides the basic steps one needs to take when filing any claim.
Outpatient Claim Filing Considerations provides specific considerations, in addition to the basics, when filing for outpatient visits.
Pharmacy, Pathology and Radiology Claim Filing Considerations provides considerations when filing ancillary care claims.
Signing Blank or Wrong Forms
We discovered this Demo requirement to sign blank forms and the use of improper forms for hospital based treatment last May and informed both ISOS and TMA and were assured this would be corrected. See Be Very Careful with Your Signature and the Demonstration
Wrong Benefit Information Taught by ISOS/Global 24
Signing blank forms where you certify that the information on the form and attached documents are correct subjects you to charges of participating in fraud and has been used by TMA in the past to convince congress that beneficiaries deliberately defraud TRICARE. In May we were assured that ISOS would correct their failure to train providers in the proper use of the forms and requiring signatures on blank forms. However in August we again found that providers were still using the wrong forms and asking beneficiaries to sign blank forms. This was again reported to TMA; notifying ISOS of their failures have proved to be fruitless. Six weeks later we found that ISOS has still failed to take any action to correct their prior miss-training.
If you must sign blank forms or the wrong form, print after your signature that the form was blank and the invoices were missing when signed and on the wrong forms note that the form indicates it is not used for Institutional services. This may protect you against charges that you participated in fraud with Demo providers if TMA decides to go after us on this again.
We are finding numerous instances of wrong information taught to Demo providers by ISOS. In most instances the training denies you rightful benefits and even after ISOS was apprised of their mistakes they failed to take corrective action. So it is essential that everyone know their rights under Philippine TRICARE Standard, and further modified by the Demo.
Some examples of wrong information
Patients were told Flu vaccines are not a TRICARE benefit. When a retiree called Global 24 they were told to purchase the vaccine and they would get it administered for free which was completely wrong. Flu vaccine along with many other vaccines are an authorized benefit regardless of what Global 24 or Demo providers tell you, see Vaccine Program.
Replacement lenses used during cataract surgery are not an authorized benefit. A survey of multiple approved ophthalmologists across two Demo hospitals resulted in the same response. This misinformation provided, by ISOS and their salesman, to providers was reported to them and TMA in early August. As of the third week in September they had not bothered to correct their errors in training. The standard replacement lens is an authorized benefit but under the Demo, due to poor training you are likely to have to pay for it up front and be led to believe it is not reimbursable. We suspect they did this to entice previously burned providers back into the same old program.
Calculating Copays When Combined with Deductibles
We and others have experienced multiple erroneous approaches to applying deductibles and copays to a beneficiary’s bill and in many cases they are wrong and require over payment of deductibles and copays. These errors have been reported to ISOS since January but they continue. Given the demonstrated lack of concern on the part of the contractor in proper training it becomes the beneficiary’s responsibility to double check all calculations and teach the providers the proper way to calculate these.
Some common misconceptions
Some Demo providers believe that a married retiree’s individual deductible goes to $300 per person from $150 if single. See Misinformation and Training on Deductibles by Global 24 aka ISOS for this and the next example.
Some Demo providers believe that deductibles apply each time one presents for care which means that the first $150 of the cost of care on a given day, plus 25% of the balance is paid by the beneficiary each time they are seen.
Some Demo providers believe that when calculating a deductible combined with a copay on the balance of a bill the copay calculation is computed on the total billed amount instead of the balance, see Cost Share Calculations.
PhilHealth and the Demo
Other health insurance (OHI) which includes PhilHealth is nothing new within the TRICARE program. The TMA and ISOS were extremely negligent when they developed the Demo by not considering OHI and having a policy in place. We even warned ISOS about this months before the Demo started but were blown off. In March a retiree was thrown out of a Demo hospital and refused care under the Demo, which he is required to use, because he had PhilHealth. We inquired of ISOS and TMA about this refusal of care and after multiple ignored emails were promised a policy by May. However, as of this writing and multiple additional inquiries, we are still waiting for ISOS and TMA to respond with the promised policy. We know from reported experiences that some Demo hospitals accept Demo patients with PhilHealth while others will not. It makes little sense because all local hospitals accept PhilHealth and patients with local insurance and the current detailed billings with PhilHealth payments meet TMA requirements. Because they appear to be frozen in place, we suggest anyone with PhilHealth check with their Demo hospital(s) to see if they will be allowed admission under the Demo before the need arises. See International SOS is Once Again Dumbfounded Over Local Health Care Industry Practices
Errors on EOBs Due to Mistakes in Claims Processing under the Demo and Philippine Unique Standard
Since ISOS took over the TOP contract we have seen a significant increase in claims processing errors. Everyone should check their EOBs closely for errors that cost them money.
A few examples:
Provider was paid less than billed under the Demo and TMA owes you a refund on copays but the check is missing.
Some EOBs missing the refund may be called interim or temporary EOBs while ISOS waits for the provider to comply with converting a local bill to the U.S. detail. See Ongoing Issues with TRICARE Demo and Standard in the Philippines.
You have PhilHealth but the EOBs fails to show any credit for OHI.
You have PhilHealth but no credit is applied towards your copay.
Claims are denied for non-certification but the wrong provider is listed on the EOB.
The EOB will indicate one amount as “Allowed” but the “Paid to Provider” amount is well in excess of what was allowed.
Denial of Payment of Claims for Pharmaceuticals under the Philippine Unique Standard
We are seeing an increasing number of claims denied on the basis that ISOS forgot to certify a hospital pharmacy when they certified the hospital and it doesn’t appear a request for certification is submitted either. In most of the cases so far, the denial appears to be in error and the pharmacy was actually listed as certified. In a few that was not the case; see A Trap Deliberately Set by ISOS and TMA or Maybe Pure Incompetence
Claims denied for Non-certification under the Philippine Unique Standard
The claims contractor is supposed to request certification from ISOS when a claim is made against a non-certified provider. Most of the time, outside hospital pharmacies, it appears they do this. However in many instances ISOS will fail to certify the provider. In many cases they will claim they could not locate the provider and declare the provider does not exist; in other words saying you filed a fraudulent claim in an attempt to defraud TRICARE. We have yet to see an actual case where the provider didn’t exist. More often it appears the ISOS staff gets lost, go to the wrong location or fail to read the address given on the claim.
Philippine Unique Standard Beneficiaries Required to Use the Demo
Other times they will claim they contacted the provider but the provider declined certification. We find this is happening more often as local providers become fed up with what they see as fraud on the part of TMA and ISOS based on their past and ongoing history in the Philippines. But we also find fairly often, if we check with the provider, that nobody from ISOS every contacted them; this happens as well when some are certified but nobody from ISOS sees them. If this is the reason given always check with the provider to confirm that they were really contacted and did they decline certification. We also suggest, when seeing a non-certified provider, to check with the provider before treatment to see if they are willing to be certified.
You also need to check the Certified List frequently as provider names come and go without explanation. In some cases they are simply errors as we have seen when claims continue to be paid since the name apparently appears on the “Official” list that the claims contractor has while it is missing on the “Unofficial” list we are required to use. In other cases the ISOS or TMA Program Integrity have tried the provider and found them guilty of fraud and they are then sanctioned in secret. Secret sanctioning results in their removal from the list but not being placed on the TMA official sanctioned list so there is no way a beneficiary can determine they were sanctioned and reimbursement for care will be refused. They will often offer some other excuse for not being certified such as the provider died or moved and/or could not be found but who is still seeing patients at the same location; see Program Integrity and Their Role in Secret Removals of Providers for “Fraud”
While TMA and ISOS saw no reason to provide training to TRICARE beneficiaries outside the Demo areas, they will deny your claims in a heartbeat if you happen to be in a Demo area and seek care. You are expected to know, apparently through osmosis, all the constantly changing rules that apply to those living within the Demo area. Make no mistake about it. Their negligence and lack of training or providing readily available written materials to the majority of beneficiaries in the Philippines, who are required to use this experiment, will find their claims denied outright and with no recourse and we have seen this happen.
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 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 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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