Tricare scrapping troubled system in Philippines to address fraud, military retiree care

Stars & Stripes ^ | 28 november, 2011 | Travis tritten

[usnavy_cop_retired]

The demand for upfront payment -- part of Tricare’s attempt to crack down on rampant fraud -- has led to a dangerous burden for veteran retirees, (snip)

“A lot of guys know they’re sick but they won’t go to the hospital because their money is slated for other things,” said Jim Tyler, director of the Subic Bay Retired Activities Office in Olongapo, which supports local veterans. “They won’t find out what’s wrong and they die.”

Tricare acknowledges that the Phillipines system is one of its most dysfunctional and troubled — so much so that the agency decided in September to scrap the program and start over, according to interviews with beneficiaries, a Department of Defense investigation and Tricare’s own assessments.

(snip)

The system is also hampered by out-of-date provider lists, access issues and repeated Tricare rejection of routine claims, including emergency care, according to some among the 8,000 retirees and dependents who are covered.

(snip)

The Philippines is the only place in the world where Tricare requires all doctors to be certified through an on-site visit and anti-fraud background check before paying out claims, according to the agency.

But its overseas contractor, International SOS, failed to conduct proper checks on Filipino doctors — medical credentials were overlooked and physical addresses not confirmed — in nearly 45 percent of examined cases, according to a September report by the Department of Defense Inspector General.

“As a result … they do not have adequate assurance that ‘certified’ medical providers actually exist or that beneficiaries always receive medical care from licensed medical professionals at accredited facilities,” the report found.

Tricare said it modified its contract with ISOS in February to improve the certification process and now requires proof that doctors are educated on Tricare policy and anti-fraud measures.

Read the full article at http://www.stripes.com/news/tricare-scrapping-troubled-system-in-philippines-to-address-fraud-military-retiree-care-1.161832#disqus_thread

[usnavy_cop_retired]

This is a good article by Mr. Tritten, but there is more to it than he was able to put in his story.

Here is a letter I wrote to the CEO of International SOS concerning the certified provider list;

Mr. Wilcox; Your latest Philippine certified provider list has repeated the data entry, data quality control standard violations that I discussed in my previous email to you. Here is an example of a “newly added” provider from your 1 December, 2011 Philippine certified provider list. This provider, Rose Pharmacy is listed below;

Professional ROSE PHARMACY INC BACOLOD CITY MANDALAGAN Pharmacy Added

Note that there is no street address for this provider. Mandalagan is a barangay in the capital city of Negros Occidental Province. This barangay has numerous streets, making locating this provider very difficult. However, by my going to the Rose Pharmacy website, I was able to find the location of this provider. This provider is located inside of the Robinson’s Place Mall in Barangay Mandalagan, Bacolod City, Negros Occidental.

The Rose Pharmacy website location for this provider is below;

BACOLOD- ROBINSON ROBINSON'S PLACE, MANDALAGAN, BACOLOD CITY +6334-4410805 +6334-4410805

Notice that a location that is easily discernible is listed on the website, along with a land line phone number and a fax number.

I think you would agree that this information is very helpful to beneficiaries looking for a certified pharmacy, especially a beneficiary who is traveling through Bacolod city and needs to get a prescription filled or re-filled, but your team in Manila failed to provide this important information. Why?

Here is another Rose pharmacy. It is listed on the certified provider list at;

Professional ROSE PHARMACY INC DAVAO CITY ILUSTRE ST Pharmacy Added

The Rose Pharmacy website lists it as being located at;

DAVAO - ILLUSTRE GENERAL ANTONIO LUNA COR. VICENTE ILLUSTRE STS., DAVAO CITY +6382-2279471

Again, a more accurate location, (I.E. General Antonio Luna corner Vincente Illustre Sts.), and gives a phone number,

Let’s look at another provider.

Professional CASTRO CLINIC DAGUPAN CITY MAYOMBO DISTRICT Obstetrics & Gynecology Added

Mayombo District, Dagupan City is a large area with numerous busy streets and Blvd’s. How is a beneficiary expected to locate this provider? I’ve spent an hour searching the internet to attempt to locate an address for this provider.

We must assume that your ISOS certification team in Manila traveled to Pangasinan province and located the Castro Clinic somewhere in the Mayombo District. But, apparently your employees did feel there to be a need to share the exact address with the Tricare Standard beneficiaries in the Philippines by including the exact address, (and the phone number which they are required to collect), of this provider on the Philippine certified provider list.

Then there are several “newly added” providers listed as being at a hospital. Great. What medical building are they in? What room number are they in? What are their phone numbers?

Maybe that is not important information to you, but it sure is to an elderly beneficiary with bad knees who must walk up and down stairs and hallways attempting to locate the certified provider.

Of the 40 “newly added” providers to the Philippine certified provider list, 27 are lacking in address details, and, of course, none have telephone numbers listed. TMA claims that ISOS is responsible for the quality control of the certified provider list data. Since this data is your responsibility, we are adamant that your company “FIX” the Philippine certified provider list immediately.

I have been complaining about the corrupted and missing data in this list for five years. Enough is enough.

Kenneth J. Fournier, MAC USN, (ret)

[bushpilot1]

How does one sign up for tricare down in Nergos Oriental?

[HiTech RedNeck]

It sounds a lot like a bad database design from the word go. There is not enough room in the fields to accommodate Philippine style addresses and phone numbers.

[cherry]

I thought everything was just dandy in the Phillipines?....

don't the expatriots come on here once in a while and tell us so?....

America might be in deep trouble but its still America...

[usnavy_cop_retired]

The data base is trash on purpose. It has allowed International SOS to “certify” a provider more than once because of the way they free hand input the data. For example, they will input; Dr. Rosales,Daniel,R. and when the claims processors looks to see if the provider on the official receipt, which says Rosales, Daniel MD, (no middle initial),is listed on the “official” certified provider list, the claims processor sees Dr. Rosales,Daniel,R. as a different provider, not the one on the official certified list. The claims processor then sends a request for a “new” certification for Rosales, Daniel MD.

ISOS then reports a certification for the “new” provider under the name that was listed on the official receipt that the claims processor has. Bingo, another certification payment by Tricare to ISOS. There is no doubt that ISOS doesn’t actually go to the provider’s office again and do a new certification.

The same problem exist with the address. If provider’s address on the “official” list does not match, number for number, letter for letter to what is on the provider’s official receipt, another certification request is made, and another payment to ISOS from Tricare.

If you want to see the “mess” that this data base is in, go to

http://www.tricare.mil/tma/pacific/pacificcertifiedproviders.aspx

then click on Philippine certified providers.

This data base is so corrupted, but for five years we have complained in letters to Tricare about the list, yet it still is trash.

Worse than this, though, is the fact that there is a list of “DENIED” providers that we are not allowed to use, but Tricare will not post the list and ISOS says it is proprietary. I got a copy of it from a FOIA request, (which took 10 months for Tricare to release it to me), and I’ve circulated it to as many Military retirees that I could, but that list is already outdated.

Tricare won’t pay a claim if the provider is on the denied list, but they will not provide us with the list so that we can ensure that we do not use a “denied” provider.

Recently, ISOS de-certified two pharmacy chains and denied all claims that had been submitted prior to the de-certification. We had to scream to high heaven that that is illegal since we had used the pharmacies in good faith prior to the de-certification and that they, (ISOS and Tricare), never notified us of the de-certification. We learned about it when some retirees claims were denied because the provider was not certified. Tricare finally had to agree with us, (probably because Mr. Tritten’s story was already in the works and they did not want that issue brought out in the article).

Here is the Tricare website notice of resolution to that issue;

Pharmacy Certification Update

Manson Drug is no longer certified as of October 1, 2011.
South Star Pharmacy is no longer certified as of November 1, 2011.

Claims with a date of service before these dates will be honored and processed by International SOS.

The funny part is that the reason they were de-certified was because South Star Pharmacy bought out Manson Drugs and the new owners, supposedly, would not cooperate with the certification process. There was no allegations of fraud, since pharmacies in the Philippines do not file claims with tricare for retiree purchases. All purchases are cash sales, (at the same price as local filipinos pay), and then the retiree files the claim.

Also, the certified provider list that we are required to use is not “official”. The claims processing contractor has made that very clear in emails to retirees when they complained that the provider was on the Tricare list that we are required to use at the time that they saw the provider. The response was, TOUGH< our list is the official list and “we never look at the Tricare list”. The official list is maintained, and updated weekly, by ISOS and given to the claims processor to use. Again, Tricare refuses to post the “official” list for us.

[AlexW]

“I thought everything was just dandy in the Phillipines?”
_____________________________________________

It is all in attitude.
In the right location and with the right people, life for a retired old goat could not be any better.

I am very happy here, and in no way would I consider returning to the USSA.
I see the country going only from bad to worse.
The Marxist now own the media and education.
How are you going to fight that?
We can not even settle on a RR type candidate to
defeat the Marxist scumbag, and that is just going from bad to worse.

That being said, I am not ex military, and I am in good health, knock on wood.
I consider myself a true Tea party type Republican American, as my roots go back to my great great great uncle, the Uncle Sam, 1812, Troy NY.

I have encountered a few “dog in a manger” FReepers.
That is their problem, not mine.
As I am now 67, I expect to live out my remaining years
listening to the surf lap at my beach, and raise my 9 month old baby boy.

[dennisw]

you randy old goat

[expatguy]

Where are you at FRiend?

An American Expat in Southeast Asia

[AlexW]

you randy old goat
__________________________

You bet :)

[AlexW]

“Where are you at FRiend?”
_____________________________________

I thought that we had communicated...maybe other Asian expats.
Sushiman and I are in contact all the time.

I am on Cebu, the third best island in Asia, as rated by Travel and Leisure Magazine.

[dennisw]

I have a friend who is over there right now. He refuses to use computers so I have to help him out with plane reservations. So I kind of know what the score is. In all seriousness, good luck with your little ones.

Then I have another friend with Filipino wife over here. They have two boys but he has a huge headache because he likes being Catholic while wifey (big shot nurse supervisor in hospital) joined an evangelical sect that she is always donating (squandering) thousands to.

[AlexW]

“he likes being Catholic”
________________________________________

Well, there are some small churches of THE Evangelical type here, but the majority is Catholic, and attend the huge 300 year old church here. Baby Alex was christened there.
I was raised as an Episcopalian, and was senior warden of the oldest Episcopal church in west Tennessee, (1832).
That is much the same as Catholic, but without a pope
and overburdening hierarchy.

Making babies is the number one industry here.
Within 100 yards of me, there must be 100 kids from infant to EARLY teen.

Anyway, I now live only on small social security, but quite satisfied with my life.
God only knows what I will do when Social Security goes bust.

[AlexW]

I thought everything was just dandy in the Phillipines?....
don’t the expatriots come on here once in a while and tell us so?....
America might be in deep trouble but its still America...
__________________________________________________

Yes, Cherry...All of us expats on FR have to endure the occasional “dog in a manger” comments, no matter which country we live in.

I usually reply by asking why America was founded.
Stop and think about it Cherry.

[dennisw]

Cebu has done it again.

It has made it as one of the best

islands in Asia, climbing one notch higher than its previous rank last year.

Discovery Shores, a resort on world-renowned Boracay Island in Aklan, also made it to this year?s list as one of the Best Resorts in Asia.

Travel + Leisure magazine recently released the results of its World?s Best Awards 2010, a listing of the best hotels, airlines, cruises islands and cities all over the world.

Cebu got a rating of 87.50 points up by 8 points of last year?s 79.68 points to climb to the number three spot from fourth last year.

Discovery Shores was ranked at no. 14 with a rating of 90.35 ? a feat considering that last year, no Philippine resort made to the listing.

Cebu trailed behind Bali (88.70) and Maldives (88.00) which maintained their last year?s ranking. Following Cebu are the islands of Koh Samui (84.63) and Phuket (80.80), both in Thailand.

http://globalnation.inquirer.net/cebudailynews/news/view/20100802-284483/TravelLeisure-magazine-2010

 

[dennisw]

Very interesting. Do you have a yard? Are you growing any veg? Any fruit trees? I suppose you get great fresh fish where you are and not expensive

[HiTech RedNeck]

All this sloppiness in managing only 8000 clients.

No private health care company would get away with such dis-service. Ironically, government regulators would be climbing all over their back.

I was involved for a while in a States based private pharmacy’s back end data operation for mail order prescriptions. On a nightly basis it reconciled prescription orders with health insurance companies and the logic was as tight as a drum.

If the multi-morphism is an attempt to get around providers who genuinely have not certified, then shame on them, but if it’s an attempt to be sure you match a whitelist, then shame on the system.

[AlexW]

“Very interesting. Do you have a yard? Are you growing any veg? Any fruit trees? I suppose you get great fresh fish where you are and not expensive”
____________________________________________________

No, I have no yard of my own, or grow anything, but I have bananas within ten feet of my front door in my neighbors yard.
Vegies are very plentiful, as my town, Dalaguete, is “The Vegetable Capital of Cebu”.
The “Utanon” (vegetable) festival is held at the first of every year.

About 8 pump boats, used for fishing, are beached less then 100 ft of me.
A pump boat is a very big canoe with outriggers, and powered
by diesel engine.
My next door neighbor builds them.
One neighbor sells his fish here on the road when he comes in, late afternoon.

I make and supply ice to fishermen, as well as neighbors
living within a half mile of me.

[usnavy_cop_retired]

ExPat; I’m in Palawan. I’ve been here for 10 years with my wife of 40 years, (who has cancer).

The problem with fraud in the Tricare Philippines system is contractor created and Tricare has been taken to task for their failure to perform oversight in several DODIG reports. the latest one is DODIG report D-2011-107 which took International SOS to task. A previous reports was D-2008-045 which placed the blame for the $100,000,000 fraud by Health Visions Corp., (HVC), directly on Tricare and it’s contractors back.

Almost immediately after HVC opened it’s doors, retirees reported suspected fraud by HVC, but Tricare did not react to it for 10 years, and only after the Defense Criminal Investigative Service and the DODIG shamed them during the criminal investigation of HVC.

Tricare’s response was to make getting medical care more difficult. To the point that in a recent meeting with retirees in the Philippines, the Tricare claims processing contractor admitted that they deny 75% of claims from the Philippine, but that the standard denial rate in the US is only 25%.

We routinely see the claims processor deny claims for $6.00 doctor’s office visits and under-payments of legitimate medical test fees. Mostly, this is because Tricare wants the claims to include detailed procedure breakdowns and CPT coding on all the minute procedures. Unfortunately, the medical claims system in the US is not used anywhere else in the world.

Philippine providers bill on a global billing system. If you go to a hospital for an appendectomy you will be quoted a firm price for the surgery prior to going into the operating room. Even if there are complications in the surgery, the price does not change because that was the quoted price.

The Philippine providers do not price their services according to the minute procedures performed. the price is based on their best estimate of what they will be doing during the surgery. and, since the CPT coding system is US specific, Philippine providers have no idea what it is or how to “work it” to ensure that their full bill is paid by Tricare.

Because of this, retirees have had to “learn” this very complicated system, (which is done in the US by 4 year college degreed medical coders/billers), in order to attempt to be reimbursed close to the actual out of pocket cost. I should explain here that in almost all foreign countries, the patient is required to pay cash for medical care at the time of discharge from the hospital, (and most times a deposit is required before you can be admitted to the hospital). Thus, the retiree has already paid for the medical care and is attempting to be reimbursed his money from Tricare, which is 75% of the “allowed” amount.

[Jet Jaguar]

Active Duty/Retiree Ping.

[dennisw]

Description: Philippines typical Pa**enger Pump Boat. This is commonly used in transporting people from one island to the other closer island. Pa**enger would be facing each other in a row in left and right side of the boat.

Why the outriggers? My guess is this helps the boat be higher out of the water so less resistance. Plus the boat can be built higher with a higher center of gravity. The outriggers make it impossible for it to capsize. So you are the local iceman. Do you have the internet in your house? Dial-up I suppose? From friends' accounts I know internet cafes are very popular in Philippines. And everyone has a cell phone. Texting sort of replaces e-mail since land lines into homes is not common so why have a computer in the house unless you get cable TV. Home computer connect via the phone lines or via cable TV provider. Or maybe.........  a private local area wireless network. That's the way to go in the 3rd world

You are all set... veg and fish and other foods. I have bananas, papaya and mangoes growing. I even have two mango trees of the Philippine mango variety