The Philippine TRICARE Demonstration, More Than Enough Fraud and Incompetence to Go Around

Definitions as defined by Merriam-Webster Dictionary;

Fraud:  a: deceit, trickery; specifically: intentional perversion of truth in order to induce another to part with something of value or to surrender a legal right b: an act of deceiving or misrepresenting: trick

Incompetent: 1: not legally qualified 2: inadequate to or unsuitable for a particular purpose 3 a: lacking the qualities needed for effective action b: unable to function properly <incompetent heart valves>

Deceit: 1: the act or practice of deceiving: deception 2: an attempt or device to deceive: trick 3: the quality of being deceitful: deceitfulness

As you read further in this narrative each of these definitions will show themselves in acts and actions by both the TRICARE Management Activity (TMA) and their sole source contractor International SOS (ISOS)

TMA hired a company, ISOS, that we know has a questionable background in past dealings with TRICARE in the Philippines to design and administer their Philippine Demonstration Project. After months of delays and policy changes and with an extremely small provider network this contractor and TMA proclaimed victory and forced beneficiaries to use this demonstration.

From the start TMA claimed that the major reasons for the demonstration were to reduce costs and eliminate fraud. To reinforce these goals they included language in the initial Federal Registry notice and the TRICARE Operations manual (TOM).

In the Federal Registry notice TMA stated; “To be included on the approved list, a provider must agree to accept reimbursement at the lower of the usual and customary charges and the established fee schedule.”

The TOM Chapter 18, Section 12, 1.0 Purpose states; “This demonstration will allow the DoD to determine the efficacy and acceptability of an alternative approach to the delivery of health care in the Philippines. The DoD TRICARE Demonstration Project for the Philippines (hereinafter referred to as the demonstration) will enable DoD to determine whether it is possible to control costs, reduce aberrant billing activity, and eliminate balance billing issues while providing high quality, safe health care to TRICARE Standard beneficiaries residing in the Philippines and receiving care in designated demonstration area(s). This will be accomplished by the establishment of a dedicated list of providers who agree to comply with certain requirements and business processes as outlined below.”

Further paragraph 2.0 Background states; “Although the number of TRICARE beneficiaries residing in the Philippines has remained relatively constant over time, there has been a significant increase in the amount billed for health care services. Administrative controls and the implementation of a government-directed foreign fee schedule have been only partially successful in containing costs. Additionally, certain billing practices in the Philippines have resulted in beneficiary dissatisfaction and excessive out-of-pocket expenses due to balance billing. Beneficiaries in the Philippines are frequently required to pay the provider or facility at the time services are rendered, and file their own claims for reimbursement. Since TRICARE reimburses these claims based on the fee schedule, a beneficiary may incur excessive out-of-pocket expenses (in addition to their normal cost shares and deductibles) if the billed charges exceed the fee schedule amount.

For the past five years TMA has closed down provider group after provider group for what they called fraud or over charging. When a group would agree to submit claims and then increase their fees from P500 to P1,000 or more TMA called that fraud and stopped paying the claims; apparently that doesn’t apply to their fraudulent program.

We will show through actual examples how the current system is full of fraud, misinformation and deceit. Further we will show how the contractor is involved in this fraud and their total failure to teach even the basics of TRICARE policy to the providers in complete violation of their contract. TMA is well aware of this fraud and contract failures to teach policy and require contractors to comply with their agreements but prefer to look the other way and defend their contractor’s fraud and incompetence as acceptable continuing past practice with this contractor’s failures.

This morning, 7 February 2013, I went into AUFMC to check on obtaining a flu shot and to check on the system of TRICARE under the Demonstration.

I arrived at 8:45 am. While waiting I had a conversation with another beneficiary and his wife. They indicated they had been waiting since 8:20 am when they were told Flor, the sole person at AUFMC that handles TRICARE, was at breakfast. They complained to me that this was the third time they had come to AUFMC to be seen without success. The first time they waited an hour for Flor to show and when she didn’t they left. The next day they arrived at 1:00 pm and were told Flor was at lunch. After waiting until 2:15 pm they again left. They also told me they had seen a provider at Sacred Heart and was required to pay P1,000 instead of the physicians normal fee of P500 under TRICARE.

At 9:00 am, Flor walked in and after waiting 40 minutes they were seen. As I watched they were told that because they were a family that, even though only the sponsor was being seen, he would have to pay the first $300 before they could start paying only the copay. Further they were advised that the new physician fee was now P1,066 and since they had not yet paid their required $300 they were required to pay the full cost of the visit at P1,066.

When they finished I was seen at about 9:15 making my wait about 30 minutes. I first asked when they accepted TRICARE patients indicating that I was told before I could not be seen on a Saturday. She confirmed that and repeated the same old and tiring comment, we only see TRICARE M-F 8-5. TMA has told me this is absolutely not true and AUFMC sees patients 24/7 and apparently nobody but me has a problem.

I then asked about getting a flu shot and Flor told me that flu shots are not a TRICARE benefit so I would have to pay for it myself. Further she said I needed a doctor’s order before I could get the flu vaccine and if the doctor agreed then I could get it. She checked my deductible and informed me, since I was married, my deductible would be $300 and I would have to pay cash for all my care until I paid that amount. Further she told me the cost of a visit was P1,066. I asked why were the visit costs now P1,066 instead of the normal P500 and she told me that TRICARE told them that was the normal charge that they were expected to charge. I then asked her to tell me who TRICARE was; did she talk to someone in Washington or where. She replied that Global 24 told them that they were to charge $26 for all TRICARE patients so they were only complying with Global 24/TRICARE’s requirement to charge TRICARE patients more than all other patients. I bet the taxpayer and Congress will be pleased with having to pay the extra fees required under TMA’s demonstration project.

During this time the Global 24 trainer, Frederick Cornejo was sitting there. So it is obvious that ISOS and TMA are well aware that the demo providers are more than doubling their charges and telling everyone that ISOS told them to do it. Further it is obvious that not only did ISOS fail to train demo providers in the very basics of TRICARE. If they did this trainer would have corrected Flor when she claimed that a sponsor’s copay when married is $300; the copay for the sponsor, married or not is always $150. Further he would have corrected her when she said that flu shots are not covered. Flu shots are not only a covered benefit but don’t carry a copay or deductible. In other words TRICARE pays for them in full. But obviously neither ISOS nor AUFMC know the basic TRICARE rules so refuse to provide basic benefits under TMA’s demo.

I have personally notified ISOS of the failure of AUFMC to provide the promised 24/7 access to care on 9 separate occasions and once to a so called senior manager Frewen in person and even challenged him to go with us to AUFMC and straighten out the mess. He chose to ignore the issue completely preferring to talk in circles about the benefits of the program; it was obvious to me he knew full well that AUFMC refused to comply with the normal requirements. ISOS has responded to my multiple official notifications to them of the failure of their contracted hospital to comply with the promised 24/7 access that they would discuss it with them. Apparently, based on what I was told today, their discussions have been a total waste of time and apparently AUFMC has told ISOS and TMA to go jump in the lake.

I even reported this constant failure of their contractor and AUFMC to TMA. You know what they told me? They said; “The AUFMC is not systematically turning away beneficiaries after hours. The AUFMC team is very supportive of the Demonstration Project and continues to see TRICARE beneficiaries.  As with any new process, there will be some caution on behalf of staff members not directly engaged in facilitating the process so there may be some hesitation regarding how they are supposed to provide support for the Demonstration Project.”

It is obvious they are in total denial and/or believe the lies told to them by their contractor. As I told them I have asked staff on 9 occasions and all with the same answer. I’ve asked the ER, Cashier, Billing Office, Information Desk, Pathology and Radiology all with the same answer. Maybe I should have asked the janitor and that was my mistake. But even now, as of today, I asked Flor, what TMA calls “The AUFMC team”, about the hours they treat TRICARE patients and she said the same as everyone else, M-F 8-5. It seems TMA as usual is in total denial and believes if they lie to us often enough that not only will they believe the lie we will also.

BOTTOM LINE, REGARDLESS OF WHAT LIES ISOS OR THEIR FRONT GLOBAL 24 OR TMA TELL, YOU CANNOT BE SEEN AT AUFMC OUTSIDE M-F 8-5 AND NOT EVEN THE JANITOR CAN HELP YOU!

I have another report from retiree who had the misfortune of being hospitalized at AUFMC. He spent two days in the hospital and was ready for discharge on a Saturday morning. But alas, as everyone knows but TMA chooses to ignore, they have nobody working after M-F 8-5 to handle TRICARE patients. So he was required to sit on the ward for two extra days, doubling his hospital stay, until Flor wandered in Monday morning. Lucky for him Monday wasn’t a holiday or he would have cooled his heels on the ward for another day. As it was his bill is now close to double what it should have been due to the fraud and incompetence by ISOS, TMA and AUFMC. I bet the taxpayer and Congress will be pleased with having to pay the extra fees required under TMA’s demonstration project.

We had an email from another retiree who had the same experience at Sacred Heart where his former physician was now overcharging him P1,000 and probably soon to increase to P1,066 per the direction of ISOS and TMA. I bet the taxpayer and Congress will be pleased with having to pay the extra fees required under TMA’s demonstration project.

We had yet another set of emails from a 4^th retiree who had a similar experience with three episodes of care. The first time he got screwed by ISOS and AUFMC and had to pay P1,000 to his long time provider who previously charged P500. The provider informed him that he was told to charge TRICARE more but if the retiree denounced TRICARE and paid cash he could get the same care for P500. At his next two visits he was wiser and followed our advice and asked how much more TRICARE visits cost and then agreed to pay cash and save the overcharge. I bet the taxpayer and Congress will be pleased to know that this beneficiary decided not to participate in the ISOS and TMA fraud and pay cash and file his own claim.

One retiree called Global 24 and they told him that all providers signed an agreement that requires they not add extra charges for TRICARE patients. He gave them the providers name and they said they would get back to him. Guess they didn’t know what the right hand was doing at ISOS. But it appears they found out that fraud is the word of the day at ISOS and never called him back.

We know of yet another retiree that was required to pay the additional TRICARE fees of P1,000 at Makati Medical Center.

So it appears ISOS made sure all providers knew to double, no more than double their charges, under the demonstration.

I’m sure there are hundreds of additional horror stories that we haven’t heard as TMA gladly begins to pay out millions of dollars in higher fees to make their dream come true. We wonder how TMA’s spin doctors will spin the millions in additional cost to beneficiaries and the taxpayer to Congress. Maybe they don’t care either.

Bottom line; don’t believe the hype and lies put out by TMA. This demonstration is fraught with fraud and higher fees and further reduces access to care. In addition to survive under this abomination one has to pay cash up front and file their own claims, so much for the hollow promises of TMA that the demonstration is in place to reduce cost, eliminate the need for beneficiaries to file claims, reduce fraud and increase access to care. You also better bone up on all the benefits and processes since the contractor ISOS failed to learn them and then failed to teach the demo providers the real rules. So be prepared to be told you are not authorized care you are and to pay double deductibles and God only knows what else they will come up with. Oh, also be sure you don’t get sick in Angeles after M-F 8-5 or bring a big wad of cash with you.

Don’t you just love this new Demo that is supposed to reduce your costs, reduce fraud and where local providers will process claims? Of course if you file your own claims you can cut your cost to less than half and don’t let TMA lie to you and say the CMAC will not allow over charges because it allows $59 for an outpatient visit. Looks like soon the P1,066 will double to P2,132 or $53 and maybe even more later.