Since the beginning of time the Defense Health Agency (DHA) and its predecessors, apply U.S. health care industry standards to the rest of the world. It also appears they are very slow learners as well as the teller of tall tales.
The most recent example is this newly posted video, New TRICARE TV Episode: How to File a Claim.
It starts out well enough and provides a little good information. They are correct that overseas we have three years to file a claim; something their contractor International SOS (ISOS) apparently isn’t aware of or prefers to put out bad information. That becomes evident when one is required to sign a form under the Demo that supposedly acknowledges your responsibilities. The form clearly states that we only have one year to file a claim and they have chosen to ignore our attempts to point out the error to them. So the only conclusion is they deliberately put out bad information. But that seems to be the norm.
After that they start to get into serious trouble. Note the demand that we submit the “Provider’s claim with diagnosis and procedure codes”. First it is not a claim but a bill. Second they forgot to mention that they expect the bill to include individual costs for each procedure.
This is not a problem for most TRICARE Overseas beneficiaries in other countries because the claims contractor accepts the global bill like we receive and adds one procedure and pays the billed amount. For example a beneficiary submits a hospital claim with a global bill from a physician for $1,000. They assign, 99232 Subsequent Hospital Visit and allow $1,000. Because of the CMAC that was designed for the U.S. medical claims system if they apply the same process to our claim they allow $41.25 and disallow $958.75. The end result, in Thailand or Japan or Malaysia the beneficiary is responsible for $250. In the Philippines we are responsible for $969.06 or 97% of the cost of our care. Is there any wonder that an analysis of the 2008 claims data for TRICARE in the Philippines showed that only 7% of the billed amount was allowed for beneficiary filed claims for inpatient professional fees?
The next place they get into trouble is when they say, “As always, if you need claims assistance, contract your TRICARE Health Care contractor.” That gets them a big horse laugh from beneficiaries every time. When we inquired with “our” contractor, ISOS, asking:
“I need assistance in filing my claims. I don’t understand how to identify the procedures and medical codes so I can assign the required cost when I get a global bill from the doctor. I live in the Philippines.”
See their response. How many feel the contractor provided a good and helpful response that was appropriate to the question and specific country?
This link also provides typical examples that the claims contractor sends out requesting the same thing and advising that your local Philippine provider is essentially a fully qualified U.S. claims processor and coder so he can convert his local global bill into a U.S. style bill.
Where does the complete and total “denial” come in?
In October 2013 every hospital and physician in the Angeles City Demo area quit in mass because they were not being paid. They were not being paid because they were not really those fully qualified U.S. claims processors and coders that ISOS and DHA claim they are. Despite their attempts to mitigate this disaster, the higher quality hospital and its associated providers are still absent and still waiting to be paid for claims prior to October 2013.
In a Stars & Stripes article, DHA hopes billing fix will bring back Philippine hospitals that quit pilot project, DHA tries to make light of the issue and claims the contractor is placing “claims liaison officers in the Philippines to help the providers with properly filing claims”. If anything this is an obvious conflict of interest. It is also discriminatory as the same level of assistance should be provided to beneficiaries who are likewise required to convert local global bills to the U.S. billing standard!
It doesn’t take a rocket scientist to see what happened and to know the previous claims made to beneficiaries for the last five years were totally and completely bogus and the primary cause of the massive denial of claims for legitimate care.
The latest infomercial or propaganda pushed out by DHA and the continued denial of tens of thousands of dollars in legitimate beneficiary filed claims because the provider really wasn’t a fully qualified U.S. claims processor and coder seem to provide more than ample proof that DHA is in continuous total and utter denial. We wonder if there are any programs like AA for bureaucrats who are at Type B denial.
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!