What would be the perfect world for a provider under the Demonstration?
Could it be one where the TRICARE Management Activity (TMA) and International SOS (ISOS) build an environment where they tell, no direct, providers to increase their fees for Demo patients up to five times the normal local rates for Filipinos and local third party payers where the U.S. designed CMAC grossly overstates local rates.
Could it be one where the TMA and ISOS build an environment where they allow and maybe encourage providers to decide which procedures they will process claims for and which they will not, thereby requiring beneficiaries to pay for the care up front and in full and file their own claim. Maybe these would be care like some laboratory and radiology procedures and surgical procedures that everyone knows the U.S. designed CMAC grossly understates local rates.
This maybe the perfect world for providers but it would be the worst possible world for beneficiaries.
These worlds now exist for TRICARE beneficiaries who have been forced against their will to participate in the TMA mandated experiment and don’t even consider the lack of quality of care checks.
It is common knowledge among beneficiaries that Demo providers have been directed to over charge when they feel like it and when the poorly designed CMAC will support fess that are significantly higher than normal local rates. Even the providers and staff will openly admit they are doing this and say they do it because TRICARE mandates they overcharge and we have witnesses and other irrefutable evidence of these conversations.
Until now, what was not common knowledge was that providers could decide that they would participate only for procedures where they can overcharge and decide which procedures they would not participate in; commonly known as cherry picking and officially sanctioned by TMA.
I predicted in an email to TMA some time back, that providers would start to cherry pick what they will process claims on and what they will not. This is due to the screwed up CMAC that was designed around the U.S. system of billing instead of the local system of billing. This resulted in many procedures having maximum allowable charges well above the local rates and many well below. I have tried to address this to TMA for almost 5 years but they chose to ignore it as they largely ignore any input. TMA and their contractor sanctioned the 2 to 5 fold increases in local fees for visits in particular and any procedure that the CMAC overstates. Now they are excluding specific procedures that the CMAC underpays and where the local providers decide they do not want to accept the loss. So they have the best of both worlds, as they can increase profits up to 5 fold in those instances where the CMAC overstates reality and require patients to pay up front and file a claim, when the CMAC understates reality, which will be denied for a significant portion of the actual amount of the local cost and in particular if they are not adept at medical coding and procedure identification and how to convert costs to the U.S. mandated standards.
We have thousands of examples of the overcharges and statements from providers and staff that TMA and their contractor sanctioned the 5 fold increases and we have written statements from TMA saying that it is acceptable for providers to over-charge TRICARE when they can. The most recent Specialty Waiver Listing provides the absolute proof of the start of cherry picking.
It states, “Positron Emission Tomography (PET) Scan Note: This specialty waiver covers PET scan services only. It does not include any other services at St. Luke’s Medical Center. This service is not fully reimbursable under current CMAC rates. Therefore, beneficiaries will need to pay upfront and submit a claim for reimbursement.”
This single act has now opened the door to hundreds more exclusions on the basis that the CMAC does not fully reimburse the local cost for any given procedure and there are thousands of them, mostly surgical and ancillary as I’ve told TMA for 5 years. Once they made this exception for one procedure for one provider they have nothing to stand on to prevent the same from happening with others. Even if they tried to stop it now they can’t. For example all an Approved Ophthalmologist has to say is he does not do Cataract removal under the Demo which would require the beneficiary seek a waiver, pay for the care himself and find that the majority will not be paid.
This indirect self admission that the CMAC is not properly designed for the Philippine medical industry has been known by retirees for years. It is reflected in the extremely high claim denial rates on beneficiary submitted claims, as high as 93% for inpatient professional fees. The data also shows TMA spends only 13%, adjusted for local cost, of what they spend anywhere else in the world on beneficiaries in the Philippines; not counting the millions being paid to their contractor for the Demo. This has cost retirees millions over the years.
What does this mean to average Joe beneficiary under the Demo? Providers will get rich and gain windfall profits at the expense of the taxpayer and the beneficiary and also in violation of local law while sanctioned and protected by TMA. They will do this by filing claims and be paid well in excess of what they get from anyone else, including other third party payers, for the same service and as much as 5 times more. At the same time, when they determine that the CMAC doesn’t cover local costs they can now notify TMA that they will not file claims for that particular procedure and TMA will add it to the list of exceptions and direct the beneficiary to pay for their own care and break out their own detailed procedure list, cost it and absorb a significant amount of the cost.
Bottom line, beneficiaries get to pay significantly higher copays on selected procedures where TMA has authorized local providers to overcharge and then pay for the full cost of care for procedures where the CMAC does not cover the local rates so the beneficiary will get to cover that cost as well. Beneficiaries are being lead to slaughter by TMA who now requires them to use these providers who they have granted permission to cherry pick procedures and overcharge or tell the beneficiary to pay for their own care.
This is the program that TMA claimed in presentations, “You will have reduced out-of-pocket costs. Approved demonstration providers have agreed to accept established reimbursement rates.” Reality seems to show neither claim is anywhere near the truth; just more rhetoric and double talk by TMA.
One has to ask the question. Does TMA treat any other group of beneficiaries in this manner anywhere else in the world? Do beneficiaries in Germany, Japan, Korea and the U.S. find that there are mandated to see selected providers who are granted approval to charge up to 5 times what they charge anyone else and then also tell patients to pay for their own care when the provider sees they are not going to be able to get as much as they expected from any given procedure because the CMAC doesn’t cover the cost. In Germany, Japan or Korea are beneficiaries required to pay a significant portion of the cost of legitimate care or are providers and beneficiaries paid billed charges? Are beneficiaries in the U.S. told that providers who they are “required” to see can decide to not accept CMAC rates and require the beneficiary to pay for the care up front and then absorb the cost of the care because the CMAC doesn’t cover it?
Bottom line, TMA has conspired with their contractor and local providers to create a situation which resembles shooting fish in a barrel; TMA, their contractor and local providers are the shooters and beneficiaries are the fish. Nothing much has changed for beneficiaries from before except their demise is much more organized now.
The best of all possible worlds for TMA, ISOS and local providers, the worst of all possible worlds for TRICARE beneficiaries in the Philippines. How many didn’t see this coming and thought TMA and ISOS had their best interests at heart?