1 February 15 List of Certified Providers Removed in Secret & ISOS Fraud


International SOS (ISOS) no longer posts lists of Certified or Approved providers as they continue to reduce their costs at the detriment of beneficiaries in the Philippines. We reviewed the total listing of providers and compared them to the previous total listing to determine any suspicious removal activity and to see the bigger picture of trends such as the continued loss of access to care in Angeles and which ISOS conveniently hides from the average beneficiary.

The providers we are concerned with were not moved to the Not Seen in > 2 Years list; also no longer available to beneficiaries. According to ISOS guidance providers that have not been used during the previous two years are moved to this list and will require recertification if used by a beneficiary. Using this logic, if a provider is removed from the primary list but is not added to this list, they were used within the previous two years. Since they were not recertified it has to be because they died, retired or went out of business. Or they are no longer considered a legitimate provider or were removed and placed on the secret sanctioned list or demanded their certification be removed. If the provider is on our list of secretly removed providers and is still practicing medicine then the only remaining reasons are they asked to be removed or ISOS secretly decided to sanction them.

In the 19 months we have been maintaining this list of secret removals and sanctioned providers, 427 providers have been removed but not one has been added to the Not Seen in > 2 Years list. That is a significant number of providers that are likely to have been sanctioned in secret and increase your risk of being denied access to care and reimbursement if you happen to choose one of these secretly sanctioned providers.

As many of you know and we have personally experienced, ISOS is well known for providing wrong or misleading information and even outright lies on occasion. The above conclusions are made based on information ISOS put on the internet with regard to removal of providers. If that was false information then ISOS once again has deliberately misinformed beneficiaries and our conclusions may not be completely correct.

Since ISOS claims this process and the outcomes are secret we suspect they want to hide their shortcomings and failures from scrutiny. We know that other regional contractors openly address their processes for accrediting providers for TRICARE and we know their claim that this process is protected by 10 USC 1102 because they are conducting “Quality Assurance Inspections” is completely bogus as no legitimate quality checks are done and our inquiry asking them to list the quality checks was ignored.

For one, the staff used for certification does not qualify as Quality Assurance Inspectors but are merely common clerks. Further the TRICARE Operations Manual (TOM) states the TRICARE Overseas Contractor is not required to conduct quality checks on providers and finally the checks made according to the TOM, Chapter 24, Section 14 – 2.3 are administrative/clerical processes such as taking a picture of a building or office and obtaining copies of licenses and similar activities.

We also know that the Defense Criminal Investigative Service (DCIS), assisted by the DODIG, found major deficiencies in the certification process and possibly other areas as well. The DCIS portion of the findings are classified. Based on previous conversations with DCIS, they likely contain criminal activity. However the DODIG portion of the findings were made public and showed significant and serious deficiencies on the part of ISOS and also on the part of DHA who failed, for years, to conduct any inspections of the process. These failures on the part of ISOS and DHA contributed to millions of dollars in fraudulent claims being filed and paid which the Defense Health Agency (DHA) then used as the basis to claim massive fraud on the part of providers and beneficiaries alike. For additional information see our Newsletter, Provider Certification; The Secret Paperwork Exercise Gone Bad.

Providers removed from the certified list in secret pose a serious threat to beneficiaries. While it is possible that they died or retired we find that is not the case with most of the ones we previously researched. So the removals are extremely suspicious and appear to involve the secret sanctioning process that is only conducted against providers in the Philippines; every other beneficiary anywhere in the world can access a list of sanctioned providers in their area.

An additional problem for Philippine beneficiaries is the Defense Health Agency (DHA) approved use of a separate list of certified, approved and Not Seen in > 2 Years lists that is another open secret. In reality, but DHA and ISOS will not tell you unless you specifically ask, there is an “official” and “unofficial” list of these providers. The official list resides somewhere in the deep bowels of ISOS and is provided to Wisconsin Physicians Services (WPS) who uses it to determine who is certified, approve or Not Seen in > 2 Years. We, on the other hand, are not allowed to see the official list but are subjected to the unofficial or what is commonly called the “Fake” list by those of us that are aware of it. Even the so called customer service clerks do not have access to the official list but are also forced to use the Fake list; just ask them where they go to find a provider for you if you call.

We are finding increasing numbers of examples of providers that were certified but are missing from the “Fake” list or are listed on the “Fake” list but are not certified or are listed on the “Official” list as Not Seen in > 2 Years. We have found similar issues with the “Fake” approved list. Detailed examples of providers that were missing or wrongly included on the “Fake” list were addressed in last month’s report on Secretly Removed Providers.

All attempts, over the last few months, to obtain an explanation as to why we are required to use a “Fake” list and why ISOS is allowed to fraudulently misrepresent the true status of providers and why beneficiaries are subsequently harmed due to delayed or denied claims has gone unanswered. However being ignored by DHA and ISOS is an expected outcome unless we continue to push the issue(s) for up to a year when eventually they will provide a response.

In the meantime and for the foreseeable future, beneficiaries forced to use one of the multiple versions of the limited Philippine TRICARE Standard will have to play DHA’s and ISOS’s version of Russian Roulette! But never forget, when you play and lose, and you will lose sooner or later, the funds stolen from you will be toted to Congress as “Cost Avoidance” in their constant fight against fraud by beneficiaries like you!

Why do we include “Fraud” in the title of this post? Fraud is defined in the Free Dictionary as A false representation of a matter of fact—whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed—that deceives and is intended to deceive another so that the individual will act upon it to her or his legal injury. We believe that the secret use of a fake list of providers which has been proven to differ from the “official” list and to the financial detriment of TRICARE beneficiaries in the Philippines clearly meets the definition of fraud.

DHA has informed Congress in writing that 77% of all beneficiaries and 66% of all providers are suspected of fraud which forces them to reduce our access to care to protect the American taxpayer. While DHA claims suspected fraud by beneficiaries and providers it is clear that there is actual fraud committed by their contractor to the detriment of beneficiaries. We also know that DHA is fully aware of this fraud and has turned their back on it for years to the detriment of beneficiaries. Isn’t it amazing how the bureaucrats at DHA have no qualms about tarnishing the reputation of 8 out of 10 military retirees, their wives and children by telling Congress they are suspected of fraud but at the same time not a word is said about actual fraud committed by their contractor against these same beneficiaries.

These are the results of our review of the “Fake” list of certified, approved and not seen in > 2 years lists:

Only two (2) providers disappeared in secret and under suspicious circumstances this month.

There was one correction to a providers address and city but at least it appears they previously got the province right. For years they had the provider, SAMPANG’S ADULT & PEDIATRIC UROLOGY, listed as ROSARIO MEMORIAL HOSPITAL, SAN ROQUE in the municipality of GUAGUA and now changed to MOTHER TERESA OF CALCUTTA MEDICAL CENTER, MAIMPIS in the city of SAN FERNANDO. Our research shows that this provider never had a clinic at for former hospital. One can only wonder if this is yet another example of a provider certified by the ISOS clerks without ever traveling to see them.

What this means to beneficiaries is if they tried to use this provider at their real location and filed a claim it would have been denied since the address didn’t match. We don’t know if the “Official” list included the correct address and city or not since all we can see is the “Fake” list.

Angeles City remains in a state of calamity due to the serious loss of access to care under 010315_0041_1January15L1.jpgthe Demo with a mere 37 physicians in a few limited specialties; a loss of one from last month. Thirteen of these physicians represent a single provider in their specialty with the majority of the remaining physicians are basic internal medicine providers. The largest single population of TRICARE beneficiaries in the Philippines is also relegated to a single hospital that many feel fails to meet basic quality standards. Eighteen months after ISOS and DHA were caught with their pants down they have been unable to recover. Unless you need only basic services from an internal medicine physician expect to pay for you care in full, obtain a waiver and pray you can get some of your money back under a system that is designed to deny payments for legitimate care.

This boils down to a less than desirable hospital along with the few physicians in very limited specialties as all that thousands of beneficiaries have to look forward to. Many of these providers offer only a few clinic hours per week which adds to the critical shortage of providers while ISOS and DHA remain silent. Considering this area contains the largest single population of beneficiaries, it speaks volumes to the almost total lack of access to care that Philippines TRICARE beneficiaries have come to see as the norm.

The following specialties still violate DHA’s mandated choice of providers forcing beneficiaries to pay for their own care or use a single provider that has never been vetted for quality. In some specialties that formerly met the choice criteria they now have no providers yet do not have waivers in place; another violation under the provisions of the Demo.

Limited Access to Care with One Facility

Hospital Inpatient Care

Laboratory Services

Radiology Services

Other Ancillary Services

Total Loss of Access to Care with No Waivers Added

Endocrinology

Pediatric Urology

This is the second time they faced a serious loss of providers and access to care under the Demo in Angeles. Eighteen months after the total loss of all providers, ISOS and DHA have still failed to recover and provide the promised “Access to Quality Care”. Instead they get whatever provider they can dig up that will agree to sometimes submit claims while more than doubling fees. This clearly shows how a poorly designed program continues to fail to provide the promised quality and access to care and in part to poor management by ISOS. Even their incentive of increasing fees up to four fold didn’t help them.

During the first briefing on this experiment we asked International SOS’s Frewen what quality checks were being done on providers added to the Approved list. His response was only Certified providers were considered. When questioned why certification constituted any kind of quality check he responded because only providers Philippine TRICARE beneficiaries used in the past were certified and therefore they must be the better quality providers.

While in an abstract way this might have some validity, then the opposite must also be true. The opposite being providers who are not certified because no beneficiaries used them or refused to use them based on what they heard about them are of low or questionable quality.

The latest Certified list includes fifty-one (51) new certified providers who are in the Demo areas. Since all beneficiaries are required to use Approved providers in these areas or face total denial of reimbursement we know almost none of these providers were certified because a beneficiary saw them, filed a claim and certification was requested pending payment. So it appears they are being certified without seeing a TRICARE patient so they can be Approved; kind of putting the cart before the horse if one cares to believe Frewen’s weak quality claim.

ISOS, using those claimed quality standards when their clerks inspect a provider, also certified the local government hospital in Naga City, Bicol. We visited this hospital when we lived in the area. This hospital in no way meets any quality standards that a TRICARE beneficiary would expect. For example there are no private or semi-private rooms, only wards. Each ward has one nurse and family is required to clean the ward and bathroom as well as administer medications obtained at the nursing station and change and clean linen.

Bottom line, ISOS and the Defense Health Agency (DHA) seem to be willing to renege on any promise or any safeguard regardless of the adverse consequences to beneficiaries to force this experiment to continue.

See List of Secretly Removed Certified Providers. It can also be accessed from the TRICARE Overseas Philippines blog’s “Useful Links” on the right under the same name. It lists all providers removed in secret and under suspicious circumstances since 1 July 2013.

We also caution beneficiaries that providers listed on the “Fake” certified and/or approved lists my not really be certified or approved and ISOS admits this by virtue of their published disclaimer although they fail to acknowledge that the list is “Fake”. In addition beneficiaries have attempted to use approved providers who denied they were approved. As with everything ISOS, buyer beware!

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?

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 Certified Provider List, Closed Network, Defense Health Agency (DHA), Demonstration, Tricare Management Activity (TMA), Tricare Overseas Program Philippines. Bookmark the permalink.

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