As some of you may know TMA made a last minute change to the rules under the experiment with just 27 working days to go before lift off. But as usual it appears nothing was thought through so they are not prepared to answer any questions regarding the affects of the new rule on beneficiaries.
See my original questions generated by the last minute change to the experiment at the bottom. Then the response from TMA and finally my response. It is apparent that once again TMA is shooting from the hip without thinking through the process as they obviously did throughout the development of the entire experiment. We are weeks away from a mandated system and TMA still can’t tell us how it works. We had a discussion with S&S yesterday on this which may have generated their inquiry. Since S&S has asked the same or similar questions we may actually get an answer in a week or two.
——– Original Message ——–
Subject: Re: Changes to TRICARE Philippines Demonstration
Date: Wed, 21 Nov 2012 08:38:08 +0800
To: Forestell, Francine, CIV, OASD(HA)/TMA
Under Standard in the States the provider’s claims staff access the beneficiaries Tricare status via the internet and determine if there is a deductible and/or copay required. That is standard practice and has been for many years. It worked that way 15 years ago and it worked that way when I was treated in Hawaii 2 years ago.
Providers in the Philippines almost never have computers available to their receptionist in their shared clinics and access to the internet in these clinics is even rarer it not non-existent. In the past various groups tried to do just what you are now requiring them to do, file claims using the unique foreign US system. In most cases TMA claimed they were defrauding them and in many cases only because they were practicing medicine IAW the local medical industry standards or because they didn’t have the benefit of a US college degreed coder and claims processor so failed to understand how to present the procedures. During these previous failed experiments many of these providers required each beneficiary pay their deductible, $150, up front at the beginning of the year and also a 25% deductible and even after they were well past their cap. In some cases they also mandated that the beneficiary pay the copay based on the billed amount with the understanding that regardless of the outcome of the claims process the money remained the providers; usually because they knew their claims for local customary fees would be under paid by the CMAC.
But beneficiaries were not mandated to use these provider groups; they still had the same right as all other beneficiaries and could chose.
Under this mandatory limited closed network we have no choice so TMA, the sole owner of this experiment, has a requirement to do it right and to think through changes in the process before implementation; not sometime after.
And yes, the system in the States is not perfect and sometimes refunds are required but it appears once again that TMA has put the cart before the horse in this experiment and once again made decisions in a vacuum and without thinking them through; perhaps because again they still think they are dealing with a US style health care system so they have all the answers.
TMA announced this experiment more than two years ago at a US based conference. Logically, one would have presumed that TMA had not only conceived the program when they announced it but worked through the details and considered the local healthy care industry issues and had a detailed working plan that had considered all the previous failures. So presumably TMA has been working on this for at least 2.5 years and the entire force of their contractor for more than a year.
Now we are 27 working days away from this experiment being mandated on thousands of innocent beneficiaries and a rule was changed primarily because TMA has been unable to recruit sufficient providers and it was hoped to pacify some more. But, again, the consequences were not thought through. Isn’t it time TMA put this experiment on hold until they work out the details and involve the stakeholders and before beneficiaries are injured or killed as a direct result of this experiment.
We await workable answers to the issues generated by this change.
Thanks for being straight forward with your answer,
On 11/20/2012 11:35 PM, Forestell, Francine, CIV, OASD(HA)/TMA wrote:
The quick answer is that this would be handled the same way that TRICARE Standard claims are to have been managed to date.
Until a claim is filed and processed, neither the beneficiary or provider know if the deductible has been met. The EOB is the means by which providers and beneficiaries are made aware of their deductible status, cost share, and cat cap. This process is not perfect and is heavily contingent on when provider/pharmacies file claims and whose hits the system first. I am not aware of what information is being made available to approved providers and has asked for clarification from the Overseas Program Office staff.
I understand these exact same questions were asked by the Stars and Stripes and are going to be vetted through the approval process. I will share the answers when they become available.
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Sent: Tuesday, November 20, 2012 5:53 AM
To: Forestell, Francine, CIV, OASD(HA)/TMA
Subject: Fwd: Changes to TRICARE Philippines Demonstration
Beyond the comments on this change in my previous email there are some very serious issues that beneficiaries need answers to. Please don’t tell me that TMA hasn’t thought of these either because this is an experiment and will take months to answer.
1 – How will a provider determine if a beneficiary has a deductible due and how much? (Without this information there is no way they can ask us to pay deductibles up front.)
2 – How will a provider determine if a beneficiary has reached the $3,000 cap and no longer has a copay?
3 – When local visit rates are $14 with a copay of $3.50 and the provider decides to go with the CMAC rate of $40 and wants a copay of $10 will we be able to refuse? If not why not?
The CMAC is not designed for the Philippines so over states many fees while understating many others. Providers will be inclined to make up for the understated fees by increasing their fees where the fees are well over local rates. I’ve informed TMA of these issues with the CMAC for years and been ignored. But now the new experiment will force me to pay more than the standard local fees. It is also possible that providers will start to cherry pick procedures and refuse to treat us where the CMAC underpays them and force us to seek care somewhere else.
How will you stop that?
4 – What process is in place to take action on behalf of a beneficiary who finds that he overpaid his deductible or copay after TMA processes the claim if they provider refuses to reimburse him? (Unlike in the states, there are not processes, except to hire an attorney and go to court. A process that will cost ten times the amount owed and take 5+ years.)
Note: Since none of you have been to the Philippines and have no understanding of how a physician works, they have no claims clerks, no accounts receivable clerks and very few have permanent clinics. Therefore they don’t have computers or staff that can be taught to access Tricare and obtain passwords to that end to verify this information. So you will not be able to use your typical US experience to claim the problem is solved.