Update on Cataract Surgery and Maybe a Newly Discovered Secret ISOS Demo Policy


Our last blog, Fake Demo Providers, Denied Patient Rights and Limited or No Access to Care included problems a retiree encountered when he attempted to use the Demo at The Medical City (TMC) for cataract surgery. But apparently International SOS (ISOS) was not through screwing with him and all beneficiaries, for that matter, forced into the limited access to care Philippine TRICARE Demo benefit.

This was not his first encounter with ISOS and their poor provider training and customer service. Seven months ago he also underwent cataract surgery at TMC only to discover that ISOS had told all Demo Ophthalmologists that lenses used as replacements during the surgery were not a TRICARE benefit and he and everyone else would have to pay in full for the unauthorized lens. His inquiry to Global 24 “customer service” was essentially ignored after he informed them that all Demo Ophthalmologists were told by the Global 24 trainers that lenses were not an authorized benefit and for seven months has not received a response. A week later he underwent the surgery and paid for the lens and filed a claim and was reimbursed in spite of the claims by the ISOS trainer. He also questioned this policy and training by ISOS with the Defense Health Agency (DHA) and was informed that ISOS was wrong and the lens was an authorized benefit. Later he was informed that ISOS acknowledged that they had retrained their staff and would retrain all Demo Ophthalmologists.

So when he saw the provider and discussed payment with his staff he mentioned that he assumed they were informed by ISOS that the lens was an authorized benefit, so would only be required to pay the copay. He was told they would text him the amount once they purchased the lens. That was on a Saturday. The following Thursday afternoon he received a text informing him that TRICARE [ISOS] told the provider that the cost of the lens was his responsibility and he would again pay for the full cost.

He immediately emailed the ISOS front Global 24 addressing the issue and asking they resolve the issue immediately as he was scheduled to leave for Manila the following morning at 0500 hours. Not receiving the normally expected automated response they received his email he followed up with a phone call where he was told there was no supervisor on duty, a typical excuse not to provide service, but his email was elevated, whatever that means. But no assistance was offered. He explained the issue with having the surgery in the morning and was assured by Mary that they would have an answer for him that evening.

You guessed it, no email, and no call, no nothing, from ISOS. He proceeded to TMC and prior to surgery stopped in the TRICARE office and asked about the forms required and completed them. After the surgery he returned to pay his copays and paid his portion of the hospital and professional fees but was informed to pay the doctor’s secretary in full for the lens the following morning when he saw the physician at 1100 hours. He knew the supervisor and many of the staff so addressed the issue to them and was told that ISOS told them that while the lens is authorized, providers have the option to require beneficiaries to pay for items under the Demo if they want and said Jennifer from ISOS or Global 24 told them that. This seems to explain why a retiree was told he would have to pay in full and in cash for inpatient professional fees at AUFMC, apparently following the same policy.

Later he was informed that ISOS and Global 24 denied they said that and because he yelled at them when he called, ISOS decided not to respond to him as apparent punishment. However he says they seldom respond to him no matter what he asks and no matter if he says ‘please’ or not; saying being ignored was just business as usual for ISOS.

Some examples he cited where they previously choose to ignore him were a question asking what the policy was concerning the TRICARE Right to Choose and the lack of choice under the Demo and a reference in their TRICARE Overseas Program Standard Health Matters Issue 2 – 2013 that said to contact them for a list of medications that require Pre-Authorization. In both instances he politely emailed them, patiently waited for days for a response and then sent a polite reminder indicating he was still waiting for an answer. In each instance he received an acknowledgement that the emails were received but even months later he has not received a single response and said these are only two examples of many.

We have received similar feedback from other beneficiaries who have found they were told someone would call or email them but then total silence. So this seems to us to be typical and, in this individuals, case an attempt to justify why they ignored the beneficiary and as punishment causing him to pay the full cost of the lens.

It seems clear that the contractor has and is failing to provide any real customer service and that what they claim is true, often times conflicts with what providers claim is true. If we had a responsible contractor, and it appears we don’t, they would have had trained staff on duty when this individual called to address his issue instead of passing the buck. They could have resolved the issue immediately by telling him the lens was an authorized benefit and they would inform the provider that he only owed a copay the next morning and to tell the hospital to call them if they had questions. (Given that ISOS claimed a few months back they retrained their staff on this subject the lack of a viable response is even more troubling and seems to indicate the training never took place.) Instead they claimed they were elevating his issue and with no assurance it would be resolved and given their long history of past failures to respond to him, he was understandably upset with being put off which seems to have been reinforced once again.

It appears ISOS and Global 24 are now claiming TMC and the provider lied to him as they never said providers could choose. In the past they have used the same tactic of claiming everyone lies about them. One example was when AUFMC failed to provide the promised 24/7 access to care. Hundreds of beneficiaries experienced this first hand when they were turned away because care was only available M-F, 8 to 5. Yet ISOS told DHA that was not true and beneficiaries simply missed the employees waiting patiently to assist them; in other words saying all the beneficiaries were stupid or liars. They also denied that they told providers that they could and should raise fees for visits and other procedures even while many beneficiaries were being told by their providers that ISOS told them to raise fees; in essence claiming all these providers were also lying to beneficiaries. The question is, does ISOS lie or do, as they claim, beneficiaries and providers lie? You have to be the judge of that but we think we know what your answer will be.

All beneficiaries need to be very careful with this contractor and the information they put out. Expect to find what they claim and what providers claim will typically be different and expect to pay cash for much of your care under the Demo. Don’t be surprised if you are told you lied or all the providers are lying when you find discrepancies.

Most of all don’t believe the hype, “You will not have to file claims for medical care received by an Approved Provider” as it is absolutely not true. First there are more exceptions than there are rules all of which require you pay in full at time of care and file a claim. Secondly, unless you want to pay copays that are two to three times higher than they should be and never get credit for your deductible, you will be forced to pay cash for visits and submit your own claims. See Clarification on External Purchase of Hospital Supplies While Receiving Inpatient Care, Policy Changes and Reversals that Dramatically Increase the Cost of Care under the Demo and Alert: Deliberate Overcharges under the Demonstration (Closed Network). In addition, if you tend to believe the staff at TMC over ISOS, there appear to be some secret rules that will also require you to pay in full at time of care if the provider chooses.

Also don’t forget the limited access to care Demo not only doesn’t apply for the majority of specialties and when hospitals don’t want to purchase supplies, it doesn’t apply in about 98% of the Philippines. When traveling outside the other 2% including driving between Demo areas be prepared to pay for 100% of the cost of your care as well. As before this fiasco, you still need to keep between $10,000 and $15,000 available to cover these costs as the part time Demo will not.

One important lesson learned here. We know from the first time the issue of payment for lenses came up multiple Demo Ophthalmologists were questioned about this and all said the same thing; they were told by ISOS that the lens was not a benefit and all apparently liars. We also know that the initial reporting of this failed to change the policy. Given the age of the retiree population and the number of Ophthalmologists that have been collecting these fees and all claiming that ISOS told them it was not an authorized benefit we suspect there are 60+ beneficiaries that got screwed by this policy and it is hard to believe all the doctors concocted the same story about ISOS. We know it will never happen but ISOS should be required to contact each of these beneficiaries that were denied their benefit and offer to reimburse them for the cost.

Anyone that reads this and was a victim of this con should write their congressman, report the con and demand they be reimbursed. If you know of someone that got sucked in advise them to read this and do the same.

But hey guys – 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!

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About TRICARE Overseas Philippines

We are U.S. Military retirees working to insure we obtain the medical benefit promised in spite of the Defense Health Agency.
This entry was posted in Closed Network, Defense Health Agency (DHA), Demonstration, Emergency Care Access, International SOS, Tricare Management Activity (TMA), Tricare Overseas Program Philippines and tagged , . Bookmark the permalink.

2 Responses to Update on Cataract Surgery and Maybe a Newly Discovered Secret ISOS Demo Policy

  1. wgraue says:

    If “Glob-24/ISOS.wire fraud.waste.abuse have your back, and suddenly appear with you in the shower, don’t bend over to pick up the soap. Beware of tall, phony former Aussie LTC kangaroos. If you don’t know what I mean, observe events more closely, and if you file a claim, all will likely become apparent on the denial date, should there ever be one.

    Like

  2. wgraue says:

    A friend of mine got the same fraudulent treatment before Tricare started its fraud zones, known as a “demonstration.” The question overall is becoming whether or not the effoft to force these bosos into doing right by you costs more in time, effort, and money than just paying in full in the first place. The answer might seem to be that we must continue to band together to break their hold on our lives, because standing alone against them or quitting is the very thing they want.

    Like

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