Merriam-Webster defines Fiasco as – a complete failure; something that has failed. That pretty much explains the TRICARE Management Activities (TMA) implementation of TRICARE in the Philippines in general. But today we want to address one specific issue, pharmacy claims. Some might consider these actions by TMA to be fraud against beneficiaries but maybe it is just incompetence on the part of TMA and ISOS; you decide.
It seems that even for pharmacy the International SOS (ISOS) and TMA can’t get it right. For years we suggested that reputable and well known pharmacy chains be certified at the national level to increase access to care and to also save TMA hundreds of thousands of dollars in contractor expense. However TMA, not being able to think for themselves, always asked ISOS if it was possible and, because they were paid by the certification, ISOS always said no. Of course this meant thousands of additional certification claims for travel expenses increasing profits for ISOS; kind of like asking the Fox to guard the Hen House. Only after TMA got tired of overcharges and they changed the contract to eliminate reimbursement to ISOS by the certification did they agree and then they agreed to what they said was impossible for years. Now it seems that TMA and ISOS have added a new twist to their claims denial, ah, we mean approval process.
The first national chain certified was Mercury Drug one of the largest, if not the largest, national pharmacy chain in the Philippines and they add new stores every month. However TMA and ISOS have added a new twist to their denial of claims process. It seems as beneficiaries learn about new, but unpublicized rules, and find ways to overcome them, TMA has to develop more unpublicized rules to keep claim approvals as low as possible.
Beneficiaries are finding that claims for prescriptions filled at Mercury Drug are routinely denied and the EOB listed reason is 018 – PROVIDER NOT TRICARE AUTHORIZED FOR THIS SERVICE; how can that be possible if every outlet is certified as TMA and ISOS proclaim. Multiple complaints lodged with TMA and their contractors finally resulted in a response that this was not acceptable and should stop; but the jury is still out. The latest new unpublicized, can we call it secret, rule is to require beneficiaries to guess the actual address listed on the “Official” certified provider list that apparently includes each and every Mercury Drug store in the Philippines.
We are not allowed to see this “Official” certified provider list but instead, occasionally, have a modified and adjusted list posted on the internet. We say occasionally because ISOS has a bad habit of ignoring the contract requirement of posting it on the required dates and TMA has to be reminded by beneficiaries to tell the contractor to do their job. See Letter Asking for Address.
Since there are no individual Mercury drug outlets listed on the “Unofficial” list it becomes a crap shoot to guess what address ISOS may have decided to assign to any particular location. We also know from when Mercury was listed that addresses made absolutely no sense and in many instances ISOS listed the same drug store 3 or more times with slightly different addresses. By looking at the last Certified Provider List before individual Mercury outlets were removed we find that the Mercury Drug in question at “Mercury Drug – Robinson Angeles” was certified three times under three different but similar addresses.
- Robinsons Big R Supercenter. Mc Arthur Highway, Balibago, Angeles City, in the city of Pampanga.
- Robinsons Big R Super Center, Balibago, Angeles City, in the city of Pampanga.
- McArthur Hwy Balibago Angeles City, in the city of Pampanga.
Doing the same thing for the other Mercury Drug we find the address listed as:
- Mercury Drug Angeles Mac Arthur. Central Luzon in the city of Angeles Mac Arthur.
- Mercury Drug Corporation – McArthur Highway Branch. Central Luzon Drug Corporation, McArthur Highway, Salapungan, Angeles City, in the city of Pampanga. (May or may not be the same outlet as 1. Above but it is anyone’s guess.)
In the second instance, that’s like listing the address for a pharmacy in Phoenix, AZ as “Southwestern U.S.” No wonder Wisconsin Physician Services (WPS) has so much difficulty in finding a real address for Mercury drug stores and why they so often claim they are not certified. It only proves, once again the axiom on database management, Garbage in Garbage out, and ISOS seems to be the master at this. See the Actual Listings.
A possible explanation for initial denial of many pharmacy claims from Mercury may have been the result of WPS trying to follow the dictates of ISOS and match the address on the claim with an address on the “Official” but secret list. When they couldn’t find a match the claim was denied. Now that we questioned this and were told that it would stop, WPS may now have to ask the beneficiary to guess the address that ISOS chose to associate with a given Mercury outlet since it is likely that even ISOS can’t guess what it is.
Days ago we quarried TMA on why these claims are again being questions but to date no response. Since TMA has refused to place the promised employee on the ground, we remain the only overseas location with a major TRICARE population without local representation to respond to and resolve issues. So we have little choice but to wait and wait.
To further explore the issues with filing pharmacy claims we did a little research and found that according to TMA, pharmacies in hospitals are no longer certified unless the hospital pharmacy is specifically certified which is another secret change as for the previous 8 years all hospital pharmacies of certified hospitals were certified. See TMA’s FAQ.
A cursory look at the latest “Unofficial” Certified Provider List shows that the pharmacies at these hospitals are not certified and therefore prescriptions filled by them will be denied. There are many more but to many to list here.
- St. Luke’s Medical Center – Manila
- The Medical City – Manila
- Sacred Heart Medical Center – Angeles City
- Angeles Medical Center – Angeles City
- Angeles University Foundation Medical Center – Angeles City
- Chong Hua Hospital – Cebu
- Sacred Heart Hospital – Cebu
- Visayas Community Medical Center – Cebu
- Baypointe Hospital and Medical Center Inc – Olongapo
- Iloilo Doctor’s Hospital – Iloilo
- Our Lady Of Lourdes International Medical Center – Olongapo
So be aware that TMA may now and without any real warning, deny pharmacy claims from the majority of certified hospitals in the Philippines after honoring them for years and without any honest warning.
One more little tidbit of information that beneficiaries might find of interest. Looking at the ISOS TRICARE web page under providers for Philippine TOP Prime Remote the list is minute and there is not one pharmacy listed which means even Active Duty and other Prime patients will have to pay for their prescriptions and then file a claim. If, after years of searching, ISOS can’t find even one pharmacy for Prime patients, what chance do you think they found one for each of the four new limited access Closed Network areas?