With the latest Approved provider list of 1 December 2013 it appears AUFMC and some of their providers have come back to see if they can lose some more money while increasing fees as directed by International SOS (ISOS).
We have to ask the question, how much fudging of the facts were done by the ISOS claims processors to insure that the physicians were not short changed by the CMAC and how much did it cost beneficiaries in increased copays? Check your EOBs and make sure they were not paid as billed charges instead of against the CMAC. If you suspect that was done email us with the details. (firstname.lastname@example.org)
Many beneficiaries have expressed concerns about being admitted to AUFMC because of concerns for quality and infection. But it appears Sacred Heart and their providers learned their lesson and stayed away. So beneficiaries are now forced to see an extremely limited selection of providers which is in direct violation of DHA’s own policies, but which apparently only applies outside the Philippines. The only quality selection criteria is they have once again agreed to take a chance on getting paid.
Chong Hua Hospital no Longer Certified and Not on the Not Used in > 2 Years List
On the Philippine Standard front it appears that DHA has secretly removed and sanctioned Chong Hua Hospital in Cebu sometime between 15 November 2013 and 1 December 2013. Last January they secretly removed and sanctioned Cebu Doctor’s Hospital. That means the two quality hospitals in Cebu are no longer available for use. Since neither hospital ever filed TRICARE claims it boggles the mind how they were found guilty of fraud against TRICARE.
When a provider simply disappears from the certified list and is not moved to the Not Used in > 2 Years list it is usually a good indicator that they were secretly tried and convicted of fraud by ISOS and/or DHA.
In the states providers that have been convicted of fraud against Medicare or TRICARE are sanctioned by not allowing them to participate or be paid by medical insurance companies. Once they are convicted they are placed on one of two sanctioned lists which are available on the internet. The more extensive of these lists can be found on the U.S. Dept of Health & Human Services. This list contains only the names of those that are currently sanctioned and contains 55,864 names mostly from the states but around 100 from overseas. Of those overseas only one is from the Philippines. The TRICARE Sanctions list appears to contain every provider ever officially sanctioned by them as the sanction has expired on a great number of them. This list contains 110 names. All of them are from the U.S. or the Philippines which has 18 of the 110 listed. Of the 18 only 8 are currently active sanctions.
But that’s not the end of the story. We know of many Philippine providers who have been removed from the Certified list and apparently tried and convicted of fraud in absentia. DHA apparently found it more convenient and expedient to bypass legal action in favor of their current process. We became aware of this process many years ago. Initially they posted a list of these providers on the TAO-P webpage but within a few months it disappeared. We asked that it be reactivated but were told that DHA was afraid of possible adverse actions they might encounter if the providers were aware they were sanctioned so refused. So for the last five years the identities of these secretly sanctioned providers have been kept secret from beneficiaries. If a beneficiary is unaware of the sanction and uses one of these providers their claims will be denied out of hand but they will not be told the truth about why it is denied.
Some indications you’re being had by the system are when you see the claim denied because the provider is not certified and the denial comes within two or three weeks of receipt by the claims contractor. If you inquire as to the reason the provider was not certified you maybe told the provider “died”, “closed their office” or “retired” on some date before the date(s) of care. Since you saw the provider you would obviously know this it false information. Another indicator is, while anyone that submitted bills and receipts for care from a non-existent provider would be investigated for fraud, they will not pursue fraud charges as they know they would be found out.
While many of these providers were involved in fraud, like the physicians that ISOS certified as tertiary hospitals so they could file false inpatient claims, we know of others that did nothing wrong and the basis for the claim of fraud was based on local policy or law which local providers have no control over.
There is little you can do about this except report it to the affected provider and complain to your congressman. We feel, in the spirit of openness, you have the right to know what is causing you to lose your benefit so decided to publish this now.