It becomes clear what constitutes fraud in the United States is not considered fraud overseas by the Defense Health Agency (DHA) when comparing the following instances of fraud. Or maybe the overseas fraud is not called fraud when DHA’s contractor is the propagator of the fraud and considered fraud only if done independently by local providers.
The recent article, Colorado Doctor to Pay Over $85,000 To Settle Improper Tricare Billing Allegations clearly demonstrated what constitutes TRICARE fraud has more to do with who committed the fraud and where it was committed than what fraud was committed.
Of particular note is the quote from the article below.
“Healthcare providers can only bill the government for the healthcare services they provide,” said U.S. Attorney John Walsh. “When they charge the government for money not owed to them, such as administrative services in this case, they can and will be held responsible for that conduct.”
As our readers know the Philippine TRICARE Demonstration contractor, International SOS (ISOS) advised and directed Demo providers to increase their fees from between two and four fold in direct violation of the primary purposes of the Demo as stated in the Federal Register notice, TRICARE Demonstration Project for the Philippines and in violation of 32 CFR, Part 199.9.
These excerpts from first the Federal Register notice and second the 32 CFR, Part 199.9 clearly show these ISOS directed increases are in violation of policy and law.
Federal Register notice:
From Supplementary Information, A. Background
“Because of this concern [excessive charges and aberrant practices], the purpose of this demonstration is to validate an alternative approach to providing healthcare services for those beneficiaries covered under the TRICARE Standard option in the Philippines, controlling costs, eliminating any balance billing issues, and ensuring that the billing practices comply with regulatory requirements.” (See Extract from 32 CFR, Part 199.9, below, for one of the regulatory requirements.)
From Supplementary Information, B. Description of Demonstration Project
“To be included on the approved list, a provider must agree to accept reimbursement at the lower of the usual and customary charges and the established fee schedule.”
From 32 CFR, Part 199.9:
“199.9 (b) (2) Improper billing practices. Examples include, charging CHAMPUS beneficiaries rates for services and supplies that are in excess of those charges routinely charged by the provider to the general public, commercial health insurance carriers, or other federal health benefit entitlement programs for the same or similar services.”
Further the DODIG, citing this practice of charging TRICARE beneficiary’s higher rates than the general public, recommended to DHA that they require all certified providers in the Philippines sign a statement that they have read and understand 32 CFR, Part 199.9. DHA concurred with this requirement and directed ISOS to implement the policy.
When we brought these obvious violations to the above requirements to the attention of DHA they first responded that we were lying about ISOS involvement since ISOS themselves told DHA they did not and would not do this.
Then they went on to say:
“There may be instances in which Institutional providers are charging up to the CMAC rate because of the added time and effort they expend to submit claims and understand the TRICARE Program. This is not an uncommon practice in the Philippines (and elsewhere in the world). Patients with medical insurance will in many cases be charged a higher fee to cover the costs of the additional effort in processing the claim and recovering their invoiced amounts as the providers are accepting financial risk of getting paid the outstanding amounts as opposed to an immediate cash payment from an individual.”
Remember what U.S. Attorney John Walsh said, “When they charge the government for money not owed to them, such as administrative services in this case, they can and will be held responsible for that conduct.”
Clearly the “time and effort expended to submit claims” and the time and effort expended to “understand the TRICARE program” and “the costs of the additional effort in processing the claim” are nothing more than administrative services.
Therefore the only logical conclusion one can draw is what constitutes fraud in the United States does not constitute fraud overseas and in particular when the TRICARE contractor is involved.
But 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!
If you want to find out the real story behind DHA’s focused attack on TRICARE beneficiaries in the Philippines instead of their spin and propaganda, read TRICARE: Betrayal in the Philippines, Is This the Future of TRICARE Overseas?