Posted on 11/26/2010 11:58:36 PM PST by usnavy_cop_retired
Open letter to all Military Retirees living overseas
Recently in an email conversation with a Tricare Management Activity, TMA, employee she told me that what they have done to us is planned to be implemented around the world, so our plight over the last few years is about to be expanded. We are attempting to get service organizations involved in this and had a petition signature drive. I have the email if anyone wants to see it.
When the Tricare Overseas Program was implemented it was done without any thought to local practices or customs and without any safeguards or checks in the system. Given the massive amount of fraud in government run medical programs in the states it wasn't surprising that some fraud would occur overseas as well. In the late 1990's an American opened a clinic for Tricare beneficiaries in the Philippines. He advertised a supplemental plan that would also cover deductibles and copays. There being a large population of beneficiaries in the Philippines and no military bases or health benefits advisers to assist with claims processing or anyway to obtain information on Tricare from TMA it took off. This group immediately overcharged Tricare and less than a year after they started retirees were already reporting that they suspected fraud to TMA. However TMA felt is was not their job to monitor fraud so ignored it and kept paying the fraudulent claims. The reports of fraud continued and even the DODIG found TMA negligent but TMA continued to ignore the fraud. Finally after ten years, two DODIG findings and a congressional mandate they took action. A joint task force was put into place to develop the steps that TMA would take. TMA brought punitive actions to the table designed to punish beneficiaries because they felt that they were to blame for all their problems; after all if they had not used the defrauders TMA wouldn't have any problems. The other members of the task force, the DODIG, DCIS and the Attorney General from Madison WI were all in favor of another action but gave in to TMA with the understanding that their punitive actions would be implemented first to be followed by their plan as the final step to return the benefit to an accessible plan while reducing fraud. However TMA apparently had no plans to honor their commitment and instead implemented all of their punitive measures, except one that Congress overruled, and disregarded their commitment to the last step.
See page 23 for an article that addresses this process at http://tinyurl.com/332jww8
These are the steps/processes the joint task force agreed to implement as well as one they implemented on their own before the task force. You can read an old but more detailed explanation of the history of the implementation of these in the article "Overview of Implementation" http://tinyurl.com/2dd4a2n Another reference that addresses some of the issues is"Issues with Tricare in the Philippines" at http://tinyurl.com/25ntgae
Certified provider list (Implemented before the Joint task force agreement)
Stop Paying Health Visions Corporation (HVC) Cap Coverage and Adequacy Legislative Changes to Sanction Beneficiaries Review Supplemental Insurance Plans for validity Eliminate Third Party Billing Increase Medical Reviews on Claims Develop a Provider Network (PPO)
Certified provider list:
The use of providers from this list is required. The official stated purpose of this list is to insure that only legitimate licensed providers are used. It is also in violation of the rules under Tricare standard which say that we can use any legitimate provider. We are told to find providers on the list posted on the web but the list is usually outdated and if we chose wrong our claim is denied with an explanation that the "official" and "up-to-date" list is with the claims processor. The process of certification is secret according to TMA and those that have declined certification are also kept secret. We know that there are more than a thousand providers, many very good ones, that have declined certification. If we need to see a provider and can't find a certified one and chose one that previously declined certification our claim is denied period. In an emergency, if we fail to use a certified provider our claim will be denied. There is almost no information from TMA on this list. Through trial and error we have learned the processes which are outlined below. This list is coming to Europe and the rest of the world in the near future if TMA has it's way.
See the following articles for more information:
Provider Certification Process: http://tinyurl.com/35d2e2s More on the secret certified Pvdr list process: http://tinyurl.com/38clq5o AD and Retiree Provider List differences: http://tinyurl.com/2vo8x3v Certification secret and a process not really to confirm a provider is real: http://tinyurl.com/3y47tda Certified Provider List Cautions and How to Use: http://tinyurl.com/2u3rf5h
Cap Coverage and Adequacy:
This process implements a CMAC that limits the amount TMA will pay for care received. The CMAC is designed for U.S. billing practices and uses a percentage of the U.S. CMAC rates. It fails to take into account local differences in payments and billing practices. Local inflation is not considered as your CMAC will be adjusted based on U.S. inflation. In our case that meant that it was increased by 10% over the last few years while local inflation increased by 35%. Exchange rates are not considered either as the rates are in dollars and your actual costs in local currency is converted to dollars based on the current exchange rate minus about 2% to cover the cost of the conversion. For example when the CMAC for the Philippines was instituted the exchange rate was about 50 to 1, or $1 bought 50 pesos. Today the rate is around 42. That's a 16% loss in value and represents an on paper reduction in the maximum allowed charges by 16%. Here is how it works. If the CMAC allows $15 for a routine office visit and the local pesos rate for a visit is 700, at the dollar value 2.5 years ago at 50 to 1 would be $14 and the entire amount would have been allowed and you would be reimbursed 75% or $10.50. Today with the peso rate at 42 to 1 the dollar value for the same 700 pesos visit would be $16.67. Since the CMAC only allows $15, $1.67 of the amount would be disallowed. So you would be reimbursed at 75% of $15 or $11.25. So your real cost would be $5.42 including the disallowed amount or 32.5% of the total cost of the care. Now consider what happens with a $10,000 hospitalization and how much extra you will pay. This doesn't even consider the amounts over the CMAC because it is designed to U.S. billing and not your local countries billing policies. We routinely see disallowed amounts on beneficiary and provider submitted claims in excess of one to two thousand dollars on professional fees for hospitalizations. In addition unless you or your physician breaks out every procedure in accordance with U.S. billing standards and lists local prices for each procedure you will find a large amount disallowed.
There are more serious issues as well.
See this article for some background on how the CMAC is developed, "CMAC" http://tinyurl.com/284z6tx
See this article that provides real examples from claims filing with an overseas CMAC, "Experiences with claims filing with an overseas", http://tinyurl.com/23vm7r7
This CMAC is coming to Europe and the rest of the world in the near future if TMA has it's way.
Stop Paying Health Visions Corporation (HVC):
This was done initially and was probably a good thing except TMA had so little understanding of how the fraud was perpetuated they also secretly stopped payment on 95% of all beneficiary claims from hospitals as well and froze these payments without explanation for six months. The reference to "Overview of Implementation" at the URL above give a more detailed explanation. This was unique to the Philippines and will not affect anyone else except to show how little TMA understands about the processes overseas and how little they care for beneficiaries. You may already find this behavior in your current dealings with them.
Legislative Changes to Sanction Beneficiaries:
They went to congress and asked that they be given administrative authority to unilaterally suspend benefits of any retiree they felt was a party to fraud or hadn’t paid their co-pays. There was no appeal process and no do process. Congress did not approve this and for obvious reasons. We are sure that if this had been approved hundreds if not thousands of beneficiaries would have been affected by this draconian measure.
Review Supplemental Insurance Plans for validity:
This process never seemed to go very far as we had already addressed the one local government plan that fell into this category which resulted in a document that allows us to use the local plan however it is cumbersome and requires every provider you use, physicians, labs, pharmacy, x-ray, etc. to jointly complete the form even though the plan specifically states it covers inpatient care only. But it may not go as well in other countries. This process is coming to Europe as well.
Eliminate Third Party Billing:
They actually never happened since this is still ongoing and the local Tricare contractor teaches them how to bill at the maximum allowable rates which TMA blames on retirees.
Increase Medical Reviews on Claims:
This is done in a number of ways all of which slow down payment of claims and targets larger claims. You maybe asked to provide copies of the hospital records on your stay. You maybe asked to complete a multipage questionnaire. The care maybe declared as inappropriate for an inpatient stay based on U.S. standards, not local standards in which case the claim is denied. The other issues will only delay payment to you for an extra month or two. The final review is to require a second proof of payment of the claim. See the article "Overview of Implementation" at the URL above which gives a more detailed explanation of the second proof of payment process. Fail to comply with this and your claim will be denied. We have documented retiree deaths due to waiting for reimbursement so they could use the money for additional care. The process is coming to Europe and the rest of the world soon if it hasn't already.
The CMAC and the Certified Provider usage requirement are the most devastating changes and all retirees living overseas should prepare themselves for a reduced benefit or take action now.
How do you take action? 1 - Join us on Facebook at http://www.facebook.com/pages/TRICARE-Overseas-The-Wall-of-Shame/113467078703149 . Read the discussions and notes sections for more information on what is coming. 2 - Organize beneficiaries around your area. 3 - Contact service organizations and ask for their help in stopping this atrocity. 4 - Write you congressman. 3 - Sign petitions like these and forward to the service organizations and congress. One is a paper petition, http://tinyurl.com/3x9f3qb One is an online petition, http://tinyurl.com/3xf6phy
Provide me with contacts, forums or military retiree groups you are aware of in other countries so we can get them involved.
Jim Houtsma
Some here will not see this as a cause to be concerned with, but if you go to TRICARE Overseas Wall of Shame
http://www.facebook.com/#!/pages/TRICARE-Overseas-The-Wall-of-Shame/113467078703149?ref=tsm you will see what we have had to put up with and the total lack of response from TMA to our request for a dialogue on these issues.
Those retirees living in other countries will be seeing these same “cost cutting” measures soon. The Philippines has been the testing grounds for these measures.
There may be governments powerful enough to counterbalance what amounts to US government medical malpractice occurring in their territories. If so, one may be well advised to retire in one of those countries.
The biggest problem for us right now is fighting the “culture” of the employees. The Tricare management doesn’t really run anything. They do what ever they are told to by the permanant workforce at Tricare. RADM Hunter’s responses to us have all been written by the attorneys and don’t respond to the questions asked.
You should see some of their replies to congrssional inquiries. All gobly-gook.
Medicare and Tricare to merge?
http://www.freerepublic.com/focus/f-bloggers/2633086/posts
BTTT
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