In a secret and underhanded move International SOS (ISOS) and the Defense Health Agency (DHA) has implemented the Philippine Demonstration Project in not only Cebu but in Davao, Baguio, La Union, Naga and in the 5th Class municipality of Lamitan, Basilan; that is if you believe the information received below.
The secret implementation applies to the entire Philippines but under obscure rules that beneficiaries in these areas were never appraised of and only apply part time. Beneficiaries know they play ‘Russian Roulette’ with ISOS and DHA everyday when they seek care and in particular when the stakes are high with inpatient care where only seven percent of all billed amounts for professional fees filed by a beneficiary are paid.[i] They now know the game is played against them with certifications where errors in the certification database that cause a beneficiary to be denied reimbursement are their fault!
The specific claim that brought this secret policy to light is one we have assisted on for more than a year and so far the beneficiary has received just few dollars out of $1,165 spent due to a series of aberrations, oversights and omissions.
But we believe there is really just a lack of training within ISOS and their subcontractor’s that causes them not to understand TRICARE policy which brought this policy to light.
The new policy seems to be in violation of the TRICARE Operations Manual (TOM), Chapter 18, Section 12, Department Of Defense (DoD) TRICARE Demonstration Project for the Philippines at change 121, dtd 6 Mar 14.
Let’s look at the circumstances involving this claim. The patient was admitted for surgery on 8 January 2013. The claim involved the hospital portion, the professional fees and outside purchases required by the hospital that chose not to pay for the items which is a normal process here. The professional fees, in the amount of $2,370, are still pending for more than a year and after multiple denials due to errors in processing. The majority of the outside purchases were denied as well because the beneficiary failed to obtain care from an ‘approved Demo provider’ while hospitalized in Cebu City since medical supply items were purchased from a business in Quezon City.
These are relevant portions of the TOM.
4.1 This demonstration is applicable to all TRICARE Standard beneficiaries who reside in the Philippines and receive care in designated demonstration area(s).
The care was not received in what was a current Demo area, Angeles, Manila or Olongapo but in Cebu City.
4.3 Demonstration area(s) will be determined by TRICARE Management Activity (TMA) and will be publicized at least 60 calendar days in advance of the effective date for each location.
We are unaware of any public or private notice that Cebu City was added as a demonstration area.
4.4 TRICARE Standard beneficiaries who reside in the Philippines, in accordance with Paragraph 4.2, and receive care in designated demonstration area(s) must receive all care from approved demonstration providers, unless a specific waiver has been granted (see paragraphs 4.8 and 4.9). If these beneficiaries receive care from a non-approved demonstration provider without a waiver, TRICARE will not cost-share the claim and the beneficiary will be responsible for 100% of the charges.
Since the care was not received in a designated demonstration area the above reference says approved providers do not have to be used.
When we became involved with these claims, June 2013, the claim for outside purchases had already been denied, but denied because the retiree failed to comply with a request for information. We were astonished when we read the letter requesting the information and heard the story.
The letter said, ‘We need a valid CPT-4 code or a detailed description of all services(s) listed on invoice 5766 as professional fees, a breakdown for each day, and the billed amount for each of those days. Please contact the provider for this information.’
When the retiree received this letter he called Wisconsin Physician Services (WPS) and tried to explain that the invoice they referenced was for intestinal staples and pointed out that, when he submitted the claim, he included a signed statement from the surgeon that described them and their purpose. An extract of that statement is below.
That proved to be a complete waste of time and money as WPS ignored the explanation from the doctor as well as his and ultimately denied the claim because the retiree failed to identify the individual procedures that these staples performed on him and what those staples charged for the services they performed.
After doing a narrative explaining the use of intestinal staples and referencing the doctor’s description along with pictures of these staples and a description of their use from the manufacture the claim was reopened. Around the same time the retiree received another letter requesting the infamous ‘double proof of payment’. He submitted the information by mail and we also submitted it by email to WPS in September 2013 and receipt was acknowledged. In November 2013 WPS again requested the ‘double proof of payment’ so we once again emailed it to them and received another acknowledgement.
Three months later, February 2014, and after not seeing any movement on the claim for outside purchase we inquired as to the status. On 3 March 2014 we were once again told the claim was still pending for lack of the ‘double proof of payment’. So for a third time we provided the information.
Then on 14 March 2014 we were informed the intestinal staples were denied for 258: service denied because care was not rendered by an approved demonstration provider. We questioned this decision and also pointed out that there were waivers in affect for these kinds of items at the time of care even if the Demo applied in Cebu. But we were so taken back by this denial we had not yet researched the policy so did not reference it. We were told; RBGM Medical Express Sales is located within a Demo area (Quezon City), however, they are not an approved demonstration provider. In addition, RBGM Medical Express Sales is not TRICARE certified, therefore the specialty care waiver does not apply. (When selecting a provider where a specialty waiver is in place, you must select a provider from the certified provider listing to ensure the claim is processed accurately and correctly.)
The statement that we are not authorized to use non-certified providers when a specialty waiver is in place is absolutely wrong as well! This is a quote from a recently approved waiver, ‘Kindly note that Dr. _____________ is not in our certified provider list. In order for TRICARE to cost share a claim, the provider must be certified, even when a waiver has been granted. If the provider is not certified, the claim will be pended and the certification process will be initiated. Once the provider is certified, the claim will be reprocessed. If the provider is not able to be certified, the claim will be denied.’ It seems clear the left hand doesn’t know what the right hand is doing when it comes to ISOS and the unique Philippine dual TRICARE programs; one has to wonder how DHA expects mere beneficiaries to know more than they or their contractor does.
The TOM, Chapter 18, Section 12, Paragraph 4.9 states in part; ‘If the Government approves the specialty waiver, the contractor shall implement processes to ensure that claims for that specialty (in the designated demonstration area) are processed under normal TRICARE Standard rules. This specialty waiver process will ensure that TRICARE Standard beneficiaries will not be liable for 100% of the charges (as described in paragraph 4.4) if the TOP contractor is unable to recruit approved providers in a particular specialty.’
Clearly if the claim is processed under normal TRICARE Standard rules (for the Philippines), a beneficiary has the choice to use a certified or non-certified provider. If they choose a non-certified provider, even if the physician chooses the provider for them, they take a chance that the, illegally secret, certification process may not certify the provider and may not be paid. But under normal TRICARE Standard rules (for the Philippines) WPS is required to request certification from ISOS and ISOS is required to initiate certification, which was denied this patient.
We want to point out that before ISOS was awarded the contract, Wisconsin Physician Services (WPS) worked hard to overcome roadblocks and claims were processed within the multiple and artificial constraints imposed by DHA with minimal errors. The staff was responsive to requests for reconsideration when errors were encountered and they were handled efficiently requiring minimal time and only a single request. But it is much different now and this is just the tip of the iceberg on claims but to address others now would make this too long. So we will follow with another article later discussing many more errors we have encountered.
We will initiate yet another appeal on this claim but we felt the public needs to know just how poorly the average TRICARE beneficiary is treated in the Philippines and how DHA, through their negligence to monitor their contractors, forces Philippine TRICARE beneficiaries to pay for their own care unless they obtain a ‘PhD’ in Philippine TRICARE policy, claims processing, medical terminology and medical coding in order to overcome the roadblocks DHA and ISOS place in front of them. Oh, and also, they need gobs of patients and understanding to endure the years it can take to succeed in seeing just one claim through to the end.
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!
[i] A review of Philippine claims data obtained via FOIA clearly showed that almost all billed amounts for inpatient professional fees were denied in total or significant portions disallowed because beneficiaries were not trained as claims processors and coders in order to comply with the DHA mandate they convert local claims or pay for the care themselves.