We’ve said for years that the Defense Health Agency (DHA) uses TRICARE beneficiaries in the Philippines as their own personal playground to test out their half baked ideas and worse, before fostering these disasters on unsuspecting beneficiaries in countries like Germany, England, Japan, South Korea, Thailand, Mexico, Spain, Italy and any number of others.
Now we have absolute proof.
I. Modified TRICARE Standard that extremely limits access to care with very few providers and no quality assurance.
In the Stars and Stripes article, DHA hopes billing fix will bring back Philippine hospitals that quit pilot project, that addressed significant problems with their Demonstration and the basic underlying concepts used to implement it, they admitted, “After it’s fully implemented, the network will include most of the 11,000 military beneficiaries in the country and could become a model for DHA overseas insurance coverage elsewhere.”
They can’t even get it right here because they have no idea where beneficiaries live and there are more exceptions then there inclusions to the Demo. More specialties are excluded than included, ninety eight percent of the Philippines are not covered by the plan and the Demo forces 11,000 beneficiaries to use two (2) distinctly different and Philippine unique plans interchangeably at the whim of DHA with their biweekly changing rules which add or remove specialties from the Demo rules; failure to keep up with two sets of rules result in absolute denial of claims. When fully implemented at most 60% will be in areas where part of their care is under the Demo and part is not; the other 40% will have the old Philippine TRICARE Standard unless they happen to pass through that 2% of the Philippines where the Demo sputters along.
II. Limit access to only providers that submit to multiple additional requirements beyond the countries normal licensure practices.
See TRICARE Operations Manual 6010.56-M, February 1, 2008, TRICARE Overseas Program (TOP), Chapter 24 Section 14 Para 2.3. DHA leaves the door open to put this insidious policy into place anywhere in the world at a moment’s notice.
When it happens be prepared to start finding claims denied because you are told the provider no longer exists, even though you know that is not true, or because the provider wants nothing to do with a corrupt contractor or DHA. In the Philippines hundreds of thousands of dollars have been saved this way on the backs of beneficiaries which DHA proudly proclaimed was cost avoidance from their fraud prevention program. You will be denied access to legitimate quality providers without notice and without a reason. Examples we see all the time; hundreds of legitimate pharmacies, internationally accredited hospitals, the Red Cross and many more. See Provider Certification; The Secret Paperwork Exercise Gone Bad; this is what you have to look forward to.
III. CHAMPUS Maximum Allowable Charge (CMAC) built for the U.S. but used overseas.
This process was developed in a vacuum with the primary focus on justify paying lower fees regardless of actual local rates. Unlike in the U.S. where there are ninety (90) different and distinct CMACs used along with add-ons for teaching facilities and exceptions for sole community hospitals that are paid billed charges, overseas countries will have a one size fits all model. When care is received and a beneficiary or provider files a claim the goal will be to minimize payment as much as possible. It won’t be long before providers who previously filed claims will opt out due to large underpayments. When beneficiaries file claims they will find significant portions of clams denied as over the CMAC which means the beneficiary foots the bill for most of the care like we do in the Philippines. This and the provider certification process are why our adjusted per capita TRICARE expenditures are just 13% of the rest of the world? See CHAMPUS Maximum Allowable Charge and Issues with the TRICARE CHAMPUS Maximum Allowable Charge (CMAC) Table for a better understanding of how DHA developed the overseas CMAC and the consequences.
Below is an extract from the DODIG Report No. D-2008-045, Controls Over the TRICARE Overseas Healthcare Program, page 23.
Of note is the “Actual Allowed Charges” are totals for the top 20 procedures in any given country. If one is to believe the results the only conclusion is that in each of these countries providers were intent on defrauding TRICARE and defrauding for more than what DHA has claimed for years was fraudulent billed amounts in the Philippines and used as the basis to add the above draconian measures.
When the DODIG used DHA’s formula to develop country specific CMACs and applied them the results clearly show the biggest defrauder is Singapore followed closely by the United Kingdom, Mexico, Panama and Italy. Only providers in Germany are defrauding the American taxpayer less than in the Philippines but still at a huge 34% over what must be local rates.
The question each beneficiary in the countries above need to ask themselves, and based on their actual experience, is are you and TRICARE being defrauded or not. No matter the answer, know that DHA believes all of this to be absolutely true and these areas are probably next on the agenda for provider certification and CMAC implementation! Bottom line as a beneficiary the percentages above will become your disallowed amounts that you have to pay but will be declared as cost avoidance by DHA.
When you consider the percentages of local charges that will be disallowed, as shown above, and the fact that in the Philippines that has resulted in a per diem TRICARE cost of 13% of the rest of the world it should be easy to see even lower per diem rates for these countries with the exception of Germany which probably wouldn’t see a drop to less than 20% of what is spent now. Of course the balance will be made up by beneficiaries just as it is in the Philippines.
So this is a heads up to you guys in other countries. If it doesn’t stop here you can look forward to all the problems and issues we are encountering in the near future. Plan to see another version of their half baked CMAC, one size fits all mirror image of the U.S. CMAC, that demands the local health care industry conform to the U.S. health care industry way of doing business. And when your versions of the “Demo” hits expect your costs to increase by 2 to 5 times over what they are now as local providers were advised to do here where the CMAC will be overlooked for Demo providers.
A word to the wise; sooner or later DHA and ISOS will turn their attention to the country where you reside and they already have the evidence they need that your country is a bigger defrauder than the Philippines. Isn’t it time to step in and help us defend “our” and “your” benefit?
Never forget the Defense Health Agency and International SOS always have your back when it comes to high quality and easy access to care; just ask them!