Skip to comments.Tricare leaves thousands of beneficiaries without medical providers
Posted on 11/01/2013 9:01:16 PM PDT by usnavy_cop_retired
Tricare leaves thousands of beneficiaries without medical providers
No, that headline is not hyperbole. It is true. In Angeles City, Philippines the two hospitals that beneficiaries are required to use, and the affiliated specialist at these hospitals, have cancelled their participation in the Tricare Demonstration Project, yet the beneficiaries are still required to use only these same medical providers for their medical care or forfeit reimbursement for their out of pocket cost for that care. Here are the details.
On 1 January, 2013 Tricare started a Demonstration Project for beneficiaries in the Philippines. Tricares contractor, International SOS, (ISOS), was tasked with establishing a network of Approved providers, (Hospitals, clinics and doctors), who would agree to treat Tricare patients, collect the 25% co-pay and deductible and then file a claim with Tricare for payment, (basically an HMO).
Tricare beneficiaries acquiring medical care in the initial three areas in the Demonstration were required to use only the Approved providers. If a beneficiary failed to use an Approved provider Tricare would not reimburse the beneficiary for his/her out of pocket cost for that medical care.
This is the rule as printed on the ISOS website;
Within Philippine Demonstration areas, if you do not seek care from an Approved Demonstration Provider and you do not receive a waiver, you will be responsible for the full cost of care.
The goal was to control what Tricare sees, (falsely), as rampant fraud committed by Philippine providers and some beneficiaries. Prior to the Demonstration there were almost no medical providers who would file claims with Tricare; it was the responsibility of the beneficiary to pay upfront for their medical care and then file a claim with Tricare for reimbursement of the cost, (minus their co-pay and deductible).
The problem with self filing was the fact that in the 2000s Tricare put in place a policy that is unique to the Philippine, (and later to Panama), that required all claims to meet the standards of U.S. medical claims. This means that the medical provider, (if he/she is filing the claim), must either provide a narrative of medical care that identifies all the minute procedures performed, or assign the appropriate Current Procedural Terminology (CPT) codes for each minute procedure performed. Failure to meet the U.S. claims filing standards results in non-payment or dramatic underpayment of the claim.
Beneficiaries have been complaining about this requirement for many years because Philippine providers do not bill for medical care using the CPT codes. Philippine providers bill on a global billing basis; they quote a fee for the medical procedure that will be performed and collect only the fee quoted when the medical care has been provided. They do not write medical narratives identifying every procedure performed. They do not use the CPT codes for their medical records or billings, (and do not know the requirements for filing a U.S. style medical claim).
Two hospitals in Angeles City agreed to participate in the Demonstration Project. They agreed to accept Tricare patients, collect their co-pay and deductible and then to file a claim for payment with Tricare. They were assured that the past experiences with Tricare of slow payments, non-payments and underpayments would not occur under the Demonstration Project. ISOS told them that they would ensure their claims were paid fully and timely.
Unfortunately, after 10 months of experiences with the Demonstration project, the two hospitals, (Angeles University Foundation Medical Center, (AUFMC), and Sacred Heart Hospital), found that their claims were not being paid in full, nor were they being paid in a timely manner. The Specialist Providers associated with these hospitals as Approved Providers under the Demonstration project, were also not being paid.
So, on 15 October, 2013 Sacred Heart Hospital and all of the Approved Specialist associated with Sacred Heart ceased accepting Tricare patients under the Demonstration rules. Unfortunately for Tricare patients, since Sacred Heart is no longer a Demonstration Approved provider, (and the associated specialist are no longer Approved Specialist), Tricare patients are prohibited from getting their medical care from these providers under threat of forfeiting reimbursement for that medical care.
On 24 October, 2013 AUFMC started refusing to provide medical care to Tricare patients unless they paid a substantial down payment upon admission and paid the total bill in full upon discharge. AUFMC also required that all laboratory and ancillary test be paid in full prior to being performed and that all Specialist must be paid in full at the time of the office visit, in-patient visit or when they perform a medical procedure.
On 31 October, 2013, under pressure from the Stars and Stripes newspaper and retirees, ISOS finally had to acknowledge that AUFMC had actually notified ISOS that as of 21 October, 2013 they would no longer participate in the demonstration Project.
As of 24, (now actually 21), October, 2013 Tricare beneficiaries in Angeles City cannot acquire medical care from the Approved Providers because the Approved Providers at Sacred Heart Hospital have had their Approved Provider status removed by ISOS, (at Sacred Hearts request), and the Approved Providers at AUFMC have elected to decline to participate in the Demonstration Project. Thus there are no Approved Providers to get medical care from under the Demonstration rules.
Unfortunately, though, ISOS and DHA have yet to suspend the mandatory requirement that all Tricare beneficiaries who seek medical care in Angeles City must only seek that care from an Approved Provider, (which are no longer available), or forfeit their rightful reimbursement for medical care under the Tricare benefit.
To be fair to ISOS and DHA, they have posted a notice that beneficiaries can use any "certified" provider or previously Approved Provider, but look at the caveat at the end of this notice;
"Healthcare services at Sacred Heart Medical Center Angeles and Angeles University Foundation Medical Center (AUFMC) as Approved Demonstration Providers are currently unavailable.
Both facilities remain Certified healthcare institutions under the Philippine Demonstration Project. Beneficiaries should continue to seek care from Philippine Approved/Certified providers in the Angeles area, including Sacred Heart and AUFMC. Beneficiaries may be required to pay upfront for these services and then submit a claim to the TOP Claims Processor for reimbursement.
International SOS is working to resolve this matter, including putting appropriate waivers in place for these institutions and associated individual providers, as needed. Additional information will be posted to this website as it becomes available.
Alternatively, beneficiaries can choose to seek care at Approved Demonstration Providers in other Phase I designated demonstration areas such as Manila to ensure their claim is cost-shared by TRICARE under the guidelines of the Philippine Demonstration Project.
As a reminder, if medical care is not received from an Approved Demonstration Provider and there is no applicable waiver in place, beneficiaries will be responsible for the full cost of care."
I think everyone would agree that this notice is so, so confusing. Are beneficiaries allowed to use certified providers and pay for their care and then file a claim, or, are they required to use Approved Providers, whom do not exist at this time?
When a reporter for the Stars and Stripes attempted to get ISOSs and DHAs side of the story, he got no response from either of them. (See http://www.stripes.com/news/two-key-hospitals-quit-tricare-pilot-project-for-retirees-in-philippines-1.249930 for the Stars and Stripes article on the Demonstration Project in Angeles City)
Why have the Approved Providers in Angeles City dropped out of the Demonstration Project? The answer is really quite simple and was the topic of numerous complaints by beneficiaries prior to the start of the Demonstration Project, and was the subject of numerous warnings to DHA prior to the roll out of the Demonstration project; claims payment amounts and claims processing turnaround time.
DHA has refused to acknowledge that requiring Philippine Providers to file claims in the manner and format that US providers must is impossible to enforce without drastically underpaying the provider for their services. Medical claims in the US are put together and filed by medical billers/coders who have spent 4 years in college learning the ins and outs of the US medical billing system, (which is unique to the US).
Military retirees in the Philippines represent 1% of the population so there is no reason for a Philippine Provider to hire a medical coder to put his claim in the format that Tricare/DHA requires, (and there are no medical coders in the Philippines because Philippine providers do not use CPT codes or detailed narratives to describe the services the provide.)
uh oh.....paradise not looking so good....
I wouldn’t call AC “paradise” - it’s mostly known for a large Red-Light district near Clarke AFB.
If I were to live on Luzon, it would be Olangapo/Subic Bay.