Certification of Hospital Pharmacies
This is either an issue of incompetence on the part of the TRICARE Management Activity (TMA) and International SOS (ISOS) or it could just as well be a deliberate attempt to inflict as much pain and harm as possible on what they consider second class beneficiaries in the Philippines.
Some time ago and for reasons never explained, TMA decided all hospital pharmacies had to be certified as well as the hospital. In other words while a hospital’s Operating Room, ICU, Laboratory, Radiology and all other ancillary services are certified under the umbrella of the hospital certification, the pharmacy is not. It therefore requires its own special certification. This policy was implemented quietly and without explanation on how to determine if a hospital pharmacy is certified. And as is usual for ISOS their quiet implementation is also inconsistent. In some cases under the hospital’s Specialty listing they will list “Pharmacy”. But in some cases, but not most, they will list the pharmacy as a provider in its own right and separate from the hospital. Which you get is pretty much left up to chance and which kid is at the computer on a given day.
This is the “Official” and complete notification of the change and requirement.
Philippines Pharmacy Changes: Effective September 1, 2011, reimbursement of pharmaceuticals in the Philippines will only be cost-shared when purchased at a TRICARE certified licensed retail pharmacy or TRICARE certified hospital-based pharmacy. Pharmaceuticals purchased from and/or billed by your healthcare provider’s office will no longer be cost-shared by TRICARE.
How many think this notice makes it absolutely clear that all pharmacies in hospitals must have their own separate certification or gives you a clue as how to tell which ones are certified. Many certified hospitals will not have certified pharmacies. One may determine that by either locating the pharmacy under the same name as the hospital but a separate entry or in some cases names different from the hospital. In those cases one has to match the address which may also not match with the hospital; a sort of pot luck approach on the part of ISOS. Alternately you can check the hospital’s certification specialty list to find “Pharmacy”.
Knowing how to determine a hospital pharmacy is certified is critical as any claims for pharmaceuticals will be denied for inpatient stays and also for outpatient prescriptions when the pharmacy is not separately certified.
Common sense, not really common at TMA or ISOS, would dictate that ISOS routinely and automatically certify pharmacies at time of certification of the hospital and would have gone back and certified all the pharmacies at currently certified hospitals given the massive importance TMA placed in this new certification. But it seems that the added expense wasn’t considered worth it for second class Philippine beneficiaries. Further, from experience we also know that Wisconsin Physician Services (WPS) doesn’t bother to request that ISOS go out and certify the hospital pharmacy as they do for all other types of providers. Instead they deny the claim on the basis the pharmacy is not certified. In the case of inpatient stays we have seen them extract any pharmaceuticals on the itemized hospital bill and deny them in a separate claim.
It’s been more than two years since this new rule was quietly put into place and during those two years TMA and their contractor ISOS have made no effort to go back and certify hospital pharmacies. Anyone care to guess how many hospitals in the Certified list don’t have their pharmacies certified? Would you guess 10? What about 30? Maybe its 50? You would be wrong. It’s 78. That’s right 78 hospitals without pharmacies. Considering that there are about 300 hospitals certified that means that almost one third of the hospitals are almost useless as an inpatient facility as you will end up paying for all your pharmaceuticals.
See Hospitals without Pharmacies to see who the 78 are! And remember when it comes to access to care and quality health care for TRICARE beneficiaries in the Philippines, TMA and ISOS have your back!