This may seem harsh but once you consider the facts and example
s below it should become clear to most, and in particular those that live under the umbrella of denial of care, that TRICARE Management Activity (TMA) Spin and Twist is common.
Much of what TMA says is couched in vague phrases that tend to avoid the obvious issue at hand and often omits pertinent information. Other times they chose to ignore the issue and either avoids it completely, address something else entirely or quote various obscure manuals that may be in existence but obviously have no impacted on the issue at hand. The term for this kind of response is commonly known as gobbledygook.
Gobbledygook is defined in Merriam-Webster as: wordy and generally unintelligible jargon. Another common tactic is to quote figures and statistics that are used to prove their point but without providing any reliable reference. However, because they are TMA and feel they are above reproach, they expect everyone to accept the data at face value. But we find the quoted figures and statistics constantly change, apparently to suit the audience or particular point they want to make. This is the Twist they add to justify their position. Twist is defined in Merriam-Webster as: to alter the meaning of: distort, pervert <twisted the facts>.
We will provide multiple examples of both of these and, unlike TMA, provide references to both their remarks and data and sources that clearly show their statements are wrong and/or distorted.
Gobbledygook
I. One example of how this works. In the S&S article, TRICARE scrapping troubled system in Philippines to address fraud military retiree care, TMA was quoted as saying “When questioned about the denial of emergency claims in the Philippines, Tricare said emergency care “never requires preauthorization” and “waivers for emergency care rendered by non-approved providers or facilities” will be considered after the fact.” We know from years of experience that is not true as thousands of claims have been denied because the provider was not certified and in many cases denied even if he was certified. But this statement was provided by TMA for public consumption only. The latter portion of the comment “…..“waivers for emergency care rendered by non-approved providers or facilities” will be considered after the fact.”, was specifically worded to imply that in fact TMA would approve emergency care in the Philippines even if the provider was not approved but WPS has no guidance that allows this consideration for Philippine claims.
Since we have continued to find claim after emergency claim is still denied we continued to pursue this injustice and recently received this statement from TMA on their emergency treatment policy in the Philippines and is quoted below.
“From talking to my colleagues at TMA, the prevailing view seems to be that, since there are thousands of providers who are certified, most beneficiaries should be able to get their emergency care from those who happen to already be on the certified list. But if a non-certified provider happens to be used, they feel that it should not be a difficult matter for SOS to certify the provider after-the-fact (assuming it is a legitimate provider).” This looks nothing like what they told S&S and obviously they will never post this as policy. Further their contention that if the provider is legitimate there should be no problem with certification clearly shows they have no idea how their broken system really works. For example in FY2009, alone, 4,240 claims were denied because the provider was not certified and 99% of those providers are real, legitimate and licensed providers. They were not certified because the “process” and the contractor International SOS (ISOS) failed and we have many examples that clearly show that. Recently the number of claims denied for non-certification, even when the provider appears on the certified provider list as grown exponentially also proving the assumption above to be wrong. A copy of the email, with the quote, can be seen at Email, but with the identification removed. The specific areas that apply are the second and third paragraphs blocked in red.
II. Another example of gobbledygook in the same article is the following; “Michael O’Bar, deputy chief of Tricare policy and operations, said the Philippines has been particularly challenging because it has one of the largest overseas retiree populations spread across remote areas and a wide array of health care providers that are difficult to monitor.
‘We have had an ongoing, large volume of communication with beneficiaries in the Philippines,’ he said. Tricare views the experimental system ‘as a significant means for us to address a number of those concerns.’” (Red highlighting ours.)
As any beneficiary in the Philippines knows there is and never has been an “ongoing” or “large volume” communication with beneficiaries. The reality is a few times a year, and then only for the last couple of years, someone from TMA arrives, pretty much in secret, and quietly holds one or two closed, invitation only, meetings were 20 – 30 people are present. Ninety percent of the people that attend these secret meetings are always the same handpicked people. In many of these meetings, beneficiaries who try to bring up issues with certification or claims are told they are not there to discuss history but talk about the future. At these same meetings the future turned out to be lengthy discussions on Prime Remote, the Tricare Dental Program and Tricare Young Adult Program; none of which are of any concern to older retirees living in the Philippines for obvious reasons. Further, when questioned about TMA holding real open meetings where the average retiree, dependents and survivors could attend we are told they are afraid for their safety and would be unable to control the anger expressed by beneficiaries, making the meetings a disaster. At least it appears they recognize how badly they have treated beneficiaries in the Philippines and know that they will not be well received; although they continue to tell the service organizations that the vast majority of beneficiaries in the Philippines are very happy with the benefit they provide.
Does anyone believe Mr. O’Bar’s goggledgook or was it really fed to S&S to appease them and any readers outside the Philippines that might find the truth troubling? Tell us what you think? Do you agree or disagree with Mr. O’Bar that they had ongoing large volume communication with beneficiaries in the Philippines? Were any of you involved in these communications and did they ask your opinion of the present program and how you felt about the closed network?
III. In mid July 2012 BG W. Bryan Gamble, M.D. Deputy Director TRICARE Management Activity posted a blog comment on DoD Live entitled, The Doctor Is In – Traveling with TRICARE. He discussed issues of traveling with TRICARE in general then some specifics on those with Prime and finished up his guidance with, “If you have TRICARE Standard and need emergency or urgent care while overseas, you should be prepared to pay up-front and submit a claim with the TOP claims processor once you arrive home.”
Of course those of us in the Philippines, where the second largest overseas population of TRICARE Standard beneficiaries live, know that it is unlikely that emergency or urgent care will be reimbursed if the provider is not certified but the BG failed to mention that very important point. So we tried to post a respectful comment pointing out the reality of access to emergency care in the Philippines under TMA’s Philippine Standard. Having previously found any comments by some of our group are routinely censured we also added a comment to that affect. As usual the comment was censored but it obviously hit a sore spot because we actually called them on their censorship where they posted their own comment that they do not censor but encourage healthy, respectful comments. The actual comment that was not “censored” but never posted can be seen at, Comment. In case they see this blog and decide to remove their comment it was preserved and can be seen at, The Doctor Is In not Censored. As long as it is not removed it can also be seen at the link in the paragraph above. But the posted comment is still conspicuously missing.
Read the comment, that they refused to post, and judge for yourself. Is it unhealthy or disrespectful? Is it untruthful? Maybe the real reason is they don’t want their gobbledygook brought to light with the facts. What do you think? Tell us your opinion of their failure to post the comment that wasn’t “censored”.
There are more but we will stop with the gobbledygook for now.
Twisted Information
I. TMA likes to throw figures around to prove their allegations of massive and ongoing fraud in the Philippines. The problem is they can’t seem to remember what figure they pulled out of the hat the last time they used it.
a. Take for example their claim that to fight fraud they have to place local providers and beneficiaries on what they call “Prepayment Review”. What that means is every claim they receive that involves a provider or beneficiary placed in this category the claim is held for review and every aspect of the claim is reviewed and double proof of payment or proof of care will be required before the claim can be processed. This is done when they suspect the individuals are involved in fraud and greatly slows down claims processing. In August 2010 TMA’s Program Integrity branch did a presentation at a conference. In that presentation, they claimed that 35.4% of all Philippine providers were under prepayment review as well as 22.3% of all Philippine beneficiaries. But not to be outdone and probably because she wanted to make a stronger point to Senator Kyl, about the “massive fraud” in the Philippines in a response to an October 2010 inquiry RADM Hunter, the then Deputy Director told him that 64% of providers and a full 77% of beneficiaries were on pre-payment review. Clearly one and likely both of them made up this figures out of thin air to support their positions at the time. Either way both can’t be correct considering the interval between the two comments.
b. Let’s look at some of the figures and statements in the TMA Federal Registry Notice that announced the Closed Network; items of interest are numbered. The notice is dated 23 Sep 2011, see item 5. Item 1 claims $59 million billed amount in 2009. Item 3 claims $17 million paid amount. On 24 Aug 2011, a month earlier, TMA held a closed door briefing in Manila for about 25 select beneficiaries and presented a slide showing historical costs in the Philippines. In that presentation it clearly showed in 2009 $81 million billed amount and $25 million paid amount. This is two examples of how their data changes with the wind.
c. The comment at item 4 is designed to imply that they have not been able to control costs. “Prepayment review is a tool typically used on a limited basis. Nevertheless, these efforts alone are not expected to control and eliminate the rising costs in the Philippines.” Now look back at the graph in the slide linked above. It clearly shows that costs have not been rising since they hit a high in 2003 and have steadily dropped even to the point that in 2010 where they are so low that per TMA’s own data presented to Congress beneficiaries in the Philippines receive around 20% of the care that all other beneficiaries around the world can expect. In light of published TMA data the statement above has no foundation in fact but is simply an attempt to dupe the reader into thinking the proposed closed network is necessary in order to stem an imaginary tide of increasing costs.
Further note the included statement “Prepayment review is a tool typically used on a limited basis.” Now go back to I.a. above and review what RADM Hunter told Senator Kyl; 64% of providers and a full 77% of beneficiaries were on pre-payment review. Would you consider that is use on a limited basis? How many agree, if RADM Hunter was telling the truth, that it is being used on a limited basis?
Finally we come to promises made to beneficiaries in the Philippines in 2007. While there are many and most have been simply ignored one clearly stands out because it was also made public to MOAA, FRA and all the other 32 members of the Military Coalition of Service Organizations. That promise was to place a TMA employee on the ground to assist Standard beneficiaries with issues with TRICARE and to provide feedback to TMA on local conditions, medical customs and practices and changes in policy to improve access to care while limiting fraud. For five years TMA dragged their feet first by using an excuse that the embassy was against the position because of the proposed location in Angeles City. Instead of moving it to Manila to remove the concern, as many of us suggested, TMA simply sat on the position for years. Finally after multiple demands by beneficiaries that they move the position they claimed they were moving it to Manila. Then they advertised a position that had no connection with Standard beneficiaries and since then they have gone silent on the position completely; apparently another promise that TMA made with no intention of following through.
Given all the evidence of how TMA operates in the Philippines is it any wonder that beneficiaries have no trust or confidence in TMA, TRICARE or anything they say or promise? How do you feel about TMA? Do you think they do a good job of administering your benefit? Do you believe anything they or their contractor ISOS tell you? Let us know what you think?
TRICARE Overseas Philippines 
I can only speak for myself, but I have only had one contact with ISOS, TMA, WPS or Tricare in 2 years. That was to address a other health insurance problem with one of my claims (OHI). As far as it being easy to get a non-certified provider certified, that is a load of rubbish. First you have to get the provider to agree to be certified, not easy with the record of Tricare being what it is in the Philippines then you have to hope that the process will be completed by ISOS in a timely manner or at all. The other statement that “since there are thousands of certified providers in the Philippines it is easy to find a certified provider for emergency care.” If you live in Manila, or one of the highly populated metro areas, that may be true in some cases. If you live in an outlaying province it may be very difficult to find a certified provider while suffering a heart attack or other medical emergency. Even in Manila, if the patient is unconscious, who is to know where he will be taken by the person or EMT assisting him, most likely it will be the nearest hospital. As my old program manager use to say when those of us in the field had a problem that we couldn’t resolve, “No problem, it is easy”. Yes no problem for him, back in the states, but for us it was a big problem that we could not fix on our own where we were.
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We know from experience that ISOS routinely claims a provider cannot be certified, either because they claim the provider does not exist or because they claim the provider refused to cooperate. Many who have been told the provider refused to cooperate find when they approach the provider that nobody from ISOS ever approached them. In my case I was told two providers that treated me did not exist. Apparently the implication was I created them and was trying to defraud Tricare. As it turned out, they later claimed they went to a mall looking for the two anesthesiologists where for some odd reason they claimed is where they had clinics. When they couldn’t find them they assumed they were not real and returned the certification requests. This process took them 90 days. I suspect this story was manufactured by ISOS once the issue was escalated as a cover story to hide what really happened. I say that because I clearly included the address including room numbers with the claim and also indicated they both needed to be certified and both had agreed to certification. The addresses I included were not at a mall but at the Medical City. Since anesthesiologists rarely operate an outpatient clinic in the Philippines since the vast majority of their work involves inpatients at a hospital the cover story that they expected to find them at a clinic at a mall becomes suspicious. And when considered with the very clear and specific addresses I included in typewritten form with the claim it becomes even more suspicious. Finally, if you even believe their story, it seems a rational and caring contractor would at least verify the address and also take a minute to find the provider. When I was told the ISOS claimed reason for denial I went to a web based physician database that ISOS customer service previously gave to me and searched for both providers. In less than one minute I had both on my screen and the addresses were identical to those I provided with my claim; not at a mall. We know that thousands of claims are denied each year for these excuses and we also know that nobody has been charged with fraud for trying to falsify a bill from a non-existent provider. We also know, based on 8 years of the actual certification database, that each year less than 0.1% of certifications result in non-certification because the provider is not a legitimate provider. I also proved that one minute of someone’s time could locate the providers. So it seems clear that ISOS and probably TMA don’t care to do certifications in an honest manner; probably because it saves ISOS money and increases their profit and TMA because they could care less about beneficiaries in the Philippines.
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I likewise talked to Generika Drugs where I had purchased generic drugs because of a hugh cost savings. They agreed to be certified. I sent in my claim in April 2011 in May 2012 I received a denial of my drug claim for lack of certification of provider. I then contacted Generika again and was informed an Executive in the head office had told them all Generika Drugs stores were currently certified, but no one visited the Generika Drug store where I had purchased the drugs. It is very clear that ISOS should be fired and TMA should be fired, why, TMA is the overseer of the contractor ISOS and it is obvious that TMA is not supervising what is happening with the contractor and since that is their jobs they are in fact defrauding the government of the United States.
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Recently the DODIG found that ISOS was seriously negligent in conducting routine certifications in that more than 45% of all certifications were lacking proper documentation as required by the contract; this was reported in one of the recent S&S articles on the horrible state of Tricare in the Philippines. They also dinged TMA and TAO-P for failure to properly monitor their own contractor. The audit, unfortunately focused on certifications and not the thousands that ISOS fails to certify which in the vast majority of cases are legitimate providers that provided legitimate care at legitimate prices but, because of ISOS and TMA negligence the beneficiary found he had to pay for 100% of the cost of his care. Since that audit and since the S&S article it appears that the number of claims denied for non-certification due to ISOS negligence has grown exponentially.
It appears the only illegitimate groups involved are ISOS and TMA. I agree Congress and the American people need to look closely at these two entities and take appropriate action to clean them up or replace them.
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Right now I am getting only about 25% reimbursement for submitted claims. Some of the claims denied were from St. Luke’s Hospital and well-respected physicians who practice there and in other reputable institutions. It seems there is always a reason to shortchange the retiree or deny the claim outright. When the 75% of “allowable charges” is granted, the percentage of reimbursement becomes dismally low. After 30 years of service and numerous deployments including OIF, OEF, etc. I am appalled at the way my fellow veterans, their families, my family, and me are being treated.
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Unfortunately Mitch TMA has put into place a number of convoluted policies that are not compatible with the local medical industry policy and customs in billing. Being bureaucrats that have never set foot in the Philippines and believe that the medical industry throughout the world is a mirror image of the American industry, they see every hospital and physician with a back office full of coders and medical billers, all trained at American universities in the American system of coding and billing. What they have never learned is that no other country in the world uses the same system of coding and billing as the U.S. so when they put a U.S. designed CMAC in place in the Philippines they caused the vase majority of hospital claims to be denied out of hand. While they are aware that, based on the amount they spend here for our medical care is less than 20% of what would be expected, they still shout to the world that we, the beneficiaries and local providers are all working together to defraud them. It is a mindset based on misinformation and false ideas of reality in the Philippines. Our only hope is to work together with service organizations and congress to force TMA to do what is right and provide an adequate level of medical care to beneficiaries in the Philippines and stop the lies and propaganda against us.
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Many thanks Jim. There is not much else I can add because it has all been said. Pls feel free to use my input in any way that may help us.
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