We posted this subject with tongue in cheek which will become clear once you read this article and the actual Army Times TRICARE Help column. You can post a comment on their link or send an email as I did.
Before we start we would like to get in contact with the individual that wrote in for help; he really does need help. If anyone that reads this Blog knows the individual please ask him to contact us so we can assist in getting his claims paid.
The question and answer are posted below with a link to it on the web. In addition we posted our email response to the email address shown in the article.
We would like to address just some of the myriad of misstatements contained in the response.
The retiree has claims amounting to more than $14,000 and has found one essentially denied and the other delayed because he is not a medical coder and claims processor; both of which are needed to file inpatient claims from the Philippines if one expects to be paid.
The response reads like it came directly from the Defense Health Agency (DHA) TRICARE Spin Doctors and not from someone that really is trying to help this poor retiree. We will comment on just a few of the more obvious wrong information and propaganda. If any has followed any of the propaganda put out by DHA in the past they can clearly see a lot of copy and paste included in this response.
“Your struggles are a reflection of a longstanding and serious problem that Tricare has had with health care fraud in the Philippines. This goes back years, it’s still not fully resolved, and it may never be. Health care fraud is a huge problem in the Philippines both within and outside the Tricare system.”
A nice start to addressing how this guy can get his claim approved. As we usually find in responses from DHA they always justify their non-payment of legitimate claims with continuous claims of “extreme” or “massive” fraud. But now it is presented as the opinion of Army Times. They claim it is still not fully resolved and we have to agree. One has to only look at the fraud involving International SOS (ISOS) where they directed local providers to increase fees 2 to 4 times above normal customary fees. A practice that DHA has defended when their contractor is involved. For more than ten years prior to that they maligned local providers, charging them with fraud and stealing millions from the taxpayer when they increased prices in a similar manner; see Policy Reversal Evidence. One can draw their own conclusions what that really means.
Let’s look at the next comment, supposedly from Army Times.
“From 1999 to 2005, dozens of doctors and Tricare beneficiaries were indicted for filing false claims. In April 2008, 17 individuals were convicted for defrauding the U.S. government of $100 million. Still, over the decade from 1999 to 2009, Tricare’s annual billed health care services in the Philippines soared from $15 million to $59 million — although the number of beneficiaries barely changed. Tricare in the Philippines also has been hamstrung by outdated provider lists and access issues.”
The truth is much different. Between 1999 and 2005 there was one incident that resulted in convictions of eleven (11) Fil-Am military retirees, not dozens. That occurred in the 2000 – 2001 timeframe. On December 11, 2006 Lutz was convicted for the HVC fraud but served almost no time. Since then there have been no convictions at least that were made public. The quoting of inaccurate billed amounts while claiming that for 10 years the population of beneficiaries didn’t increase is a favorite tactic of DHA’s Spin Doctors’ and which has been proven time and time again to be totally false based of DOD official population data maintained by the DOD Actuary which is available on the web for all to see. In fact the population increased by more than 10% during this time. Inflation of more than 50% is also conveniently ignored in this attack on us. Further if one looks at paid instead of billed amounts an entirely different story appears. And if one looks at more recent data from 2010 and 2012 one can see that the real story is TRICARE payments in the Philippines are almost non-existent, less than 7%, when compared to the rest of the world, see Access to Care, Jiving Congress & Hiding Under the Skirts of Contractors.
When they said “Tricare in the Philippines also has been hamstrung by outdated provider lists and access issues.” They got that right. ISOS and at the consent of DHA has provided substandard provider lists for close to 15 years which coupled with the secret certification process insures additional denied claims. The reference to “access issues” is almost laughable considering current data shows per diem payments in the Philippines are less than 7% of what they should be.
One comment was true however and what DHA has never admitted before.
“And unfortunately, in cases such as yours, the responsibility for providing sufficient documentation to support health care claims falls on the beneficiary.”
This is the one truth included in this attack on TRICARE beneficiaries in the Philippines. We all know full well we have to become medical coders and claims processors in order to provide the “sufficient documentation” required of only beneficiaries in the Philippines. The sad part is while DHA essentially admitted to this in a Stars & Stripes article they still claim we can ask any local provider to do the conversion for us while they claimed to have hired experts to assist Demo providers who couldn’t do the conversions.
There is more misleading and wrong information but we will leave it to you to read it for yourself.
We couldn’t let this slide and we want to get in contact with the individual so we can assist them and hope Army Times responses to our request that they put the individual in contact with us.
We can only wonder how local newspapers and other media would take to these constant attacks on the integrity and honesty of the entire Philippine health care industry between Army Times and ISOS articles claiming the same.
We encourage each of you to use the same email address we used, email@example.com, to voice your displeasure at the poor advice and maligning of beneficiaries and health care providers in the Philippines.
The question and answer from the Army Times Tricare Help column.
Q. I’m a military retiree. My spouse and I have adopted two children in the Philippines who are registered as my dependents for Tricare eligibility purposes. The children recently became ill. In February, one sustained a bad infection that cost me almost $1,000. I submitted his claim twice, and each time Tricare asked for more information. I finally received $162, but Tricare said even more information was needed before it would reimburse the other $813. Then in May, the other child sustained a mosquito bite that caused grave damage — shutting down of major organs, dialysis, lung surgery and more. I submitted a claim May 5 for that bill, which totaled almost $13,500, and still have not received a reply. I have since resubmitted the claim. Why is Tricare making this so difficult?
A. Your struggles are a reflection of a longstanding and serious problem that Tricare has had with health care fraud in the Philippines. This goes back years, it’s still not fully resolved, and it may never be. Health care fraud is a huge problem in the Philippines both within and outside the Tricare system.
From 1999 to 2005, dozens of doctors and Tricare beneficiaries were indicted for filing false claims. In April 2008, 17 individuals were convicted for defrauding the U.S. government of $100 million. Still, over the decade from 1999 to 2009, Tricare’s annual billed health care services in the Philippines soared from $15 million to $59 million — although the number of beneficiaries barely changed. Tricare in the Philippines also has been hamstrung by outdated provider lists and access issues.
Tricare officials say that the Philippines is especially challenging because it has one of the biggest U.S. military retiree populations of any foreign nation, and that population is spread across remote areas.
All these issues have led Tricare to set its bar comparatively high on claims for care received in the Philippines, and repeated requests for additional detailed information on a particular claim is not at all uncommon.
The latest chapter in this long-running saga opened last year with the launch of Tricare’s “Philippines Demonstration Project,” the most recent attempt to bring some order to the chaos. In designated demonstration areas, beneficiaries are required to see Tricare-approved providers who have agreed to comply with certain Tricare requirements and business processes in order to receive payment from Tricare for health care claims. More details are here: militarytimes.com/tricare/philippines.
No doubt all of the above is cold comfort to you in pursuing your payment claims on behalf of your children. And unfortunately, in cases such as yours, the responsibility for providing sufficient documentation to support health care claims falls on the beneficiary.
Any claims may be appealed through the Tricare Management Agency. A fact sheet on the process can be downloaded at this link: militarytimes.com/tricare/appeals.
Our email to the Army Times email address above. We sincerely hope they will put this retiree in contact with us.
Much of what was told this poor man is bogus but a good story for the officials that constantly scream fraud. In fact most will believe this came directly from the Defense Health Agency (DHA) Public Affairs Office and not Army Times. Most of us would expect better from this publication! I suggest whoever wrote this response should take some time and read the book entitled TRICARE: Betrayal in the Philippines, Is this the Future of TRICARE Overseas?
The real problem is that this guy needs to become a medical coder and claims processor in order to file his claim and DHA is well aware of this but prefers to hide from the truth although they admitted to the problem in Stars & Stripes more than a year ago.
Your claim that he can appeal through a now extinct agency, TMA, is also of little comfort. TMA died when DHA came into existence or more realistically the name was simply changed. You should have told him his appeal will go to the contractor and maybe but unlikely it will get elevated to DHA after a year or two. But until he learns to code and convert his claim from the local standard to the US standard he is wasting his time.
Bottom line he will get nothing except more aggravation from the appeal process unless he learns medical coding and claims processing to convert his local claim to the unique US standard.
I spend many hours every day doing just this for many beneficiaries and am fairly successful in getting them much more than the normal 7%, minus copay, they get on average for inpatient professional fee claims as shown in TRICARE’s own claims data.
I doubt my comments will see the light of day but at least have some mercy on this retiree and provide him with my email address and ask him to contact me so I can get him more of what TRICARE should have already paid. I charge nothing for this service.
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!