Tricare Philippines Newsletter 20120402
Background of TRICARE in the Philippines and the policies implemented under the guise of fraud prevention
As military retirees living in the Philippines know their TRICARE plan is inherently different from any other plan offered by the TRICARE Management Activity (TMA). TMA generally refuses to discuss these differences with affected retirees while claiming the policies are necessary to preclude fraud. The truth is TMA is responsible for much of the fraud through their past neglect, lack of action and because of some policies that promote fraud and poor controls over their contractor.
Why did TMA feel these policies were necessary in the Philippines?
The TRICARE Overseas Program (TOP) became reality in 1996 which extended benefits to eligible beneficiaries overseas. TMA was ill prepared to initiate, manage and monitor this program as the DODIG indicated in multiple investigations. In the U.S. fraud prevention for government sponsored medical programs like TRICARE is accomplished by other agencies so TMA had no background or experience with dealing with fraud and resisted involvement, claiming it wasn’t their responsibility. This standoff allowed the fraud to continue unabated for ten years. The second largest overseas population of beneficiaries was in the Philippines. It was also distinguished in that TMA had no local representation to monitor the program or educate beneficiaries unlike in places like Germany where every military hospital had multiple Health Benefits Advisors who assisted with obtaining care on the local economy and filing claims. So beneficiaries in the country with the second largest overseas population were left to their own devices and to fend for themselves. This combination made the Philippines ripe for fraud and should have come as no surprise to TMA.
Defense Criminal Investigators tell me that about 10% of providers in the states are involved in fraud and the same percentage was valid in the Philippines, based on their 12 years of working with fraud here. So it was not surprising when fraud got a foothold in the Philippines TRICARE program. Even then it wasn’t Filipinos but an American that developed the first major fraud through Health Visions Corp. (HVC). Within the first year of operation retirees reported that they suspected fraud and continued to report fraud for ten years. Yet TMA did little or nothing to stop the fraud and even ignored DODIG recommendations to use administrative controls that would have put a stop to the fraud early on. Instead they allowed the fraud and bleeding to continue for ten years and then tried to place the blame on retirees for using these services. See page 17, Audit Response, of the DODIG report 06-051. TMA continued to ignore the remedies they had at hand and continued to ignore the DODIG calls for administrative action in favor of more draconian measures. See DODIG report 08-045.
In November 2006 TMA started to implement measures which would have far reaching affects on beneficiaries.
What are these policies that were unique to the Philippines?
1. Stop Paying Health Visions Corporation (HVC)
2. Legislative Changes to Sanction Beneficiaries
3. Review Supplemental Insurance Plans for validity
4. Cap Coverage and Adequacy
5. Eliminate Third Party Billing
6. Increase Medical Reviews on Claims
7. Develop a Provider Network
Stop Paying Health Visions Corporation (HVC): TMA stopped paying HVC in November 2006 but also secretly stopped paying claims from beneficiaries without notifying them by ceasing payment of claims involving about 95% of all hospitals within the Philippines. This process appears to have been applied deliberately to harm the very people they were charged with providing health care. Most of the hospitals that were on the denial list did not benefit from the HVC fraud and their investigations had to have shown that.
Finally, about six months later, beneficiaries were notified of the freeze on payments via a notice on the internet. An uproar resulted and they dropped all but six facilities owned by HVC from the freeze. I suspect they realized they were on shaky ground. Their 2006 Report on Fraud conveniently ignores that they did this but thousands of beneficiary filed claims were not paid for more than six months. This was followed by threatening letters to a significant number of the original hospitals, many of which were not involved in the fraud. While TMA later backed off from these threats, they never apologized to those falsely accused and it set the tone for how hospitals and physicians feel about TRICARE in the Philippines from that point forward.
Legislative Changes to Sanction Beneficiaries: They went to congress and asked that they be given administrative authority to unilaterally suspend benefits, for up to ten years, of any retiree they felt was a party to fraud or hadn’t paid their co-pays. There was no appeal process and no due process. Congress did not approve this back in 2007 but that hasn’t stopped them from continuing to ask congress for this power to this day.
Review Supplemental Insurance Plans for validity: The initial outcome of this policy was TMA notifying their claims contractor to deny all Philippine claims where the beneficiary indicated they had OHI on the claim form but failed to provide an EOB; most often due to the family having Philhealth. The new policy required that the beneficiary include an EOB from Philhealth before the claim would be considered. Since Philhealth doesn’t provide a standard EOB recognized by TMA, these claims were simply denied. Our group worked with TMA and after about six months we got them to recognize a local form we created and they modified that, when submitted with claims from the Philippines, would be recognized in lieu of an EOB from Philhealth. However TMA doesn’t seem inclined to advertise this or make it easy to find. A copy is available from us, OHI Checklist.
Cap Coverage and Adequacy: This is better known as the CMAC or CHAMPUS Maximum Allowable Charge table and one of the major causes for limited access to care and claims denial and to a large extent because TMA had little idea of how to do it. Nor were they too concerned with the consequences to beneficiaries or providers; it was just one of their rapidly put together methods to stop fraud to pacify the DODIG and congress. TRICARE CMACs in the U.S. are a derivative of Medicare CMACs so this was their first attempt at developing one from scratch and they wanted to make it fast and simple. Their approach was to tag onto a report from the World Bank, International Comparison Program (ICP), and from that extract what is called Purchasing Power Parity (PPP) rates for the Philippines. In a nutshell the medical PPP rate is an average across all levels of care in a country, public and private, and reported as a percentage of U.S. cost based on the current exchange rates at the time the data was gathered. It’s well documented that these rates are not appropriate to use as TMA intend to use them but it met the fast and simple criteria. History now clearly demonstrates that retirees are required to shoulder an increasing share of legitimate health care costs because the allowable charges computed with this system are generally lower than local normal and reasonable costs charged to local citizens.
Using this rate they proposed to take the average CMAC rate in the U.S., there are hundreds of rates designed for every state by urban and rural areas to account for regional differences, to create one set of rates for the entire Philippines. The percentage they proposed was 22.9% of that in the U.S. which the PPP rate suggested. Our group fought these rates as to low because the percentage included an average that included government hospitals, where as TRICARE beneficiaries would be using private facilities and physicians which were at the higher end of medical care costs. We were successful in getting them changed to 52% for outpatient and inpatient care and raised to 100% of the Puerto Rico rates for ancillaries including laboratory and radiology. However even this did not truly address the actual local costs and rate setting and didn’t solve many of the problems with the CMAC. What these are and how to overcome some of them will be discussed in later newsletters.
Eliminate Third Party Billing: The plan was to remove the ability of someone, other than the actual provider, from submitting claims for the provider in the name of the billing activity. This is one of the tactics HVC used. They would use a local provider to see a beneficiary, pay them the local rate, and then bill TRICARE 3 to 5 times the local rate in their name. Their plan failed primarily because their contractor failed to enforce this policy and in, at least the past, extracted payments from these groups to certify them even though they did not meet requirements.[i]
Increase Medical Reviews on Claims: The purpose of this policy was to place some providers and beneficiaries under increased scrutiny if they were suspected of fraud. However the rules or criteria are not published but we know, based on recent written comments by TMA, that they claim 64% of all Philippine providers are under prepayment review and 77% of all beneficiaries. They further claim 90% of all their fraud resources are dedicated to checking these claims. To put this into prospective, a family of four would have three beneficiaries suspected of being involved in fraud. If this same family of four sees a total of four providers then two to three of them are suspected of being involved in fraud as well. Obviously these figures are questionable but further TMA’s case to congress to approve their ability to unilaterally impose beneficiary sanctions and maybe the reason they claim they are so high.
From a beneficiaries’ prospective this means that a growing number of providers refuse to accept TRICARE and process claims; many are now even refusing to be certified as shown by the recent wholesale refusal to be certified by two national pharmacy chains; not the comment on the bottom of the Certified Provider web page. WebPage Beneficiaries on prepayment review find that their claims take longer to process and every minute detail is questioned including the double proof of payment requirement being triggered at a much lower dollar threshold. In the case of beneficiaries on prepayment review many items that would normally be approved without question are kicked back for further proof of care or denied.
Develop a Provider Network: According to an article by Mr. Daniel M. Boucek, Special Agent in Charge, Defense Criminal Investigative Service, DoD all the members of a workgroup accept TMA agreed that the best and most effective approach to reducing fraud while maintaining a high level of access to care was a locally contracted network such as a local PPO and even recommended at least one such group[ii]. The article goes on to indicate that TMA tends to resist changes and in particular changes they did not bring to the table. So instead of taking this approach which would have greatly increased access to care, eliminated the need for beneficiaries to pay for care up front and eliminate most of the fraud they opted, as indicated in the article, to implement the more draconian measures they came up with and addressed above; most of which have proven to be ineffective in stopping fraud but instrumental in greatly reducing access to care and reducing reimbursement of claims to almost nothing. The full article describing the workgroup, the issues involved and the recommendations can be seen by going to Boucek Article.
Recently TMA started looking into a modified local provider network, they call it their “Closed Network”, but instead of leveraging a local group as recommended by every other member of the group they are trying to design one with the look and feel of a Prime network in the U.S. and based on U.S. standards including detailed coding and costing of claims all of which is completely foreign to the local medical community. A later newsletter will address what we know of this proposed program and the issues we see coming from it.
In future newsletters we will address in more detail the consequences of these policies that negatively impact on access to care and reimbursement for care. We will explain how they work in practice, how and why they cause reduced access and increased claims denial. We will provide work-a-rounds and other steps beneficiaries can take to alleviate or minimize the adverse affects these policies have on their ability to obtain and be reimbursed for care.
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[i] The implementation of the Certified Provider requirement occurred as an administrative action shortly after HVC can into existence and has been a contributor to fraud in the Philippines since. When TMA added the Philippine unique requirement that claims would be paid for care provided by certified providers, the stated purpose was to insure that only care provided by licensed and properly trained providers would be considered. In reality the contractor and or its staff used this process to their own advantage. We have proof that the contractor used to extract payment to certify providers who were not eligible for certification in exchange for a fee. (We reported this and other fraud for years but no action was taken. But recently TMA posted on the TRICARE Pacific webpage a notice declaring their contractor does not charge fees for certification and asks to be notified if it happens. While this seems to be an admission of past fraud there is still no apparent action against the contractor.) WebPage But even today we know of admin offices certified as Physician Groups and local providers certified as working at these groups so the local group can still pay the provider for care provided in their office and bill TRICARE at well over the local rates. Even as late as 2010, we were aware that some physicians that the contractor certified as a hospital were still billing as a hospital and being paid although it was reported to TMA by us in 2007. This may be still going on. A review of the 2009 claims data also points to the TMA contractor over charging for Prime care that they paid for and then processed claims for reimbursement; similar to what HVC did. These and other acts on the part of the contractor have a continued detrimental effect on our access to care and claims payment because TMA wrongly points to beneficiaries and local providers as the responsible parties for this fraud.
[ii] TMA’s continued reluctance to take any action to address the HVC fraud prompted the formation of this group made up of the Defense Criminal Investigative Service (DCIS), the investigative arm of the Department of Defense (DoD) Office of Inspector General (OIG), along with the United States Attorney’s Office in Madison, Wisconsin and TMA. It appears TMA brought the draconian measures to the table while the rest brought one recommendation which was a contract with a local, in country, contractor to provide the care such as a PPO or HMO, which has yet to be considered by TMA.