The Demonstration; Where We Stand after Six Months 13006

Posted on: July 9th, 2013 by admin No Comments

U.S. Military Retirees of the Philippines Group

Tricare Philippines Newsletter 13006

The Demonstration; Where We Stand after Six Months

If you care to listen to the TRICARE Management Activity (TMA) briefings on their Demo, everything is coming up roses or everything is peaches and cream or any similar platitude. At least this is what some of the service organizations say they hear each time they meet with TMA and they dismiss any mention that anything might be wrong. Of course those giving the speeches will never travel to the Philippines nor do they have to endure the mistakes, omissions, poor training and constant unilateral changes that beneficiaries are forced to endure. Given they didn’t see fit to place an independent observer on the ground to monitor and report back issues and make recommendations is a clear indication how little they care about our wellbeing.

The TMA claimed the following about the Demonstration

From their presentation

  • You will have access to providers who deliver high-quality medical care.
  • You will not have to file claims for medical care received by an Approved Provider.
  • You will be responsible for your deductible and cost shares, but you will not be required to make up-front payments.
  • You will have reduced out-of-pocket costs.

From their public notice on the Demonstration

  • Ensure that billing practices comply with regulatory requirements
  • Select providers that show a lack of past fraudulent billing practices
  • Provider must agree to accept reimbursement at the lower of the usual and customary charges and established fee schedules

We are on the ground and we have been fighting the battles and suffered the arrogance of TMA and International SOS (ISOS) and their constant avoidance of providing direct responses through begging the question or when pushed just saying it is none of our business; they like to claim the information is proprietary or secret.

So what is our assessment?

On the surface and to the casual observer it may appear that the kinks have been worked out and the system of care is working as planned with providers and beneficiaries satisfied with the program. But below the surface and from the beneficiaries who try to use the Demo we find a much different story.

To address these issues we will look at the following areas.

  1. Access to care
  2. Quality of care
  3. Program changes
  4. Beneficiary satisfaction
  5. Provider satisfaction

Access to care

What is access to care? There is any number of definitions. One comprehensive explanation can be found from an Abstract from the Journal of Health Services Research & Policy, July 2002 issue. The four essentials aspects of access to care, as described in the article, are;

  1. Availability of services
  2. Affordability of services
  3. Physical accessibility of services
  4. Acceptability of services

The TMA offers no access standards for TRICARE Standard but does specify the following access standards for Prime.

These include:

  • The wait time for an urgent care appointment should not exceed 24 hours (one day).
  • The wait time for a routine appointment should not exceed one week (seven days).
  • The wait time for a specialty care appointment or wellness visit should not exceed four weeks (28 days).
  • Primary Care available within 30 minutes from your home.
  • Specialty Care available within one hour from your home.

An additional access standard is addressed under the TRICARE Right and Responsibilities webpage.

  • You have the right to: Your choice of health care providers.

The Demo is a mix of Prime and Standard rules, essentially the worst of both. On the one hand we have the limited access that Prime endures but not the benefit of the lower costs associated with Prime but have to pay the higher cost shares associated with Standard.

Given these parameters let’s look at how the Demo stacks up.

Availability of Services

SpreadOne

This breakout shows the number of specialties by Demo area that have no providers available under the Demo and the percentage of total specialties. This also shows that for the majority of specialties, beneficiaries will have to pay up front and file a claim.

This breakout shows the number of specialties by Demo area that have only one provider. Not being able to chose a provider is a violation of DoD’s patient Bill of Rights, see discussion and link earlier. So even within those specialties, that TMA claims offer care

SpreadTwo

under the Demo, we are subject to one provider who has not been subjected to any real quality criteria. The primary criteria per TMA are to pass the smell test by their fraud unit and to agree to file claims.

There is a global waiver for anesthesia. This means no matter what approved hospital you use or which approved doctor under the Demo you will be required to pay the anesthesiologist in full at time of discharge and file your own claim and doing your own breakout of procedures and cost.

1. There is no official policy on OHI and PhilHealth. Some Demo patients find they are allowed to use the program while others are thrown out on their ear and told to pay for their own care and file their own claims. In at least some of the instances, Makati Medical Center (MMC), where the patient was accepted with PhilHealth there is evidence that the hospital and physicians are accepting the payment from PhilHealth but not reporting it when they file the claim. This results in double payment for part of the care and should be considered fraud. It also causes the beneficiary to pay more than they should. See TMA and ISOS Caught with Their Pants Down Once Again!

2. Continuity of Care Waivers are not really what they seem and it appears ISOS and TMA deliberately mislead beneficiaries at the start of the Demo. Continuity of care means the continuation of care with a provider that has been treating you for years and is aware of your conditions and issues. By not allowing real continuity of care waivers, TMA has eliminated continuity of care within the Demo. After the fact we were told that these waivers were good for only 90 days at a time. See Continuity of Care Banished by TRICARE Management Activity; Waivers are Secretly Good for 90 Days Only
Considering the above, we feel the first major criteria under access to care, availability of services, is pretty much a failure. When you also consider DoD’s own claim that TRICARE patients have the right to choose a provider which has been eliminated for Demo patients it is even more so. We give them a grade of D in this area.

Affordability of Services

1. One of the major selling points TMA tried to push when developing the Demo and what they told Congress and the Service Organizations was that “You [beneficiaries] will be responsible for your deductible and cost shares, but you will not be required to make up-front payments.” At the very last minute and unilaterally TMA reversed this policy forcing beneficiaries to pay deductibles and copays upfront. The reason as stated by their contractor was that they were not able to get providers to sign on unless they eliminated this significant benefit. To try to cover their betrayal of beneficiaries they told Stars & Stripes ‘”Beneficiaries may be asked to pay their applicable cost share and deductible at the time of the visit,” Camacho wrote in an email to Stars and Stripes. “This change was implemented due to beneficiary and provider feedback.’ See Retirees still to face upfront medical payments in Philippines. Since we were present at the single meeting with 17 veterans in Manila when the contractor tried to sell this change we know that beneficiaries did not provide positive feedback but instead offered multiple concerns. Yet TMA cared little for the consequences to beneficiaries and were driven to force this system to work at all cost.

2. Because the change above was not thought through but made to force a poorly designed system to stay alive, beneficiaries have found that many claims for care where they paid 100% of the cost have yet to be filed. In many cases beneficiaries have found that they have to pay their deductibles over and over again. When we inquired as to what provisions were in the provider’s contracts that would require them to file these claims we found that Frewen from ISOS continued to beg the question. We were finally able to pin him down on a teleconference where he told us what was in the contracts with providers was proprietary and therefore none of our business; in essence conceding that there is absolutely not requirement to file a claim if a provider doesn’t want to. What we know is that TMA and their contractor’s “proprietary” and secret contract relies on an incentive of non-payment of the portion owed by TMA to get providers to file claims. The gist of the agreement is that providers will not hold beneficiaries responsible for more than their deductibles and copays. If those were not collectible until after a claim was filed, as was the original claim, then there wouldn’t be a problem. But now they have no incentive. As of this writing we are aware of multiple retirees who paid 100% in January and who are still waiting for claims to be filed. See After Action Report, ISOS Demonstration Teleconference

3. TMA said, “You will have reduced out-of-pocket costs”, and they said, “Provider must agree to accept reimbursement at the lower of the usual and customary charges and established fee schedules”. Based on feedback from multiple providers to multiple veterans and feedback, before witnesses, from hospital staff that process claims, TRICARE [the contractor] suggested and even required that providers increase their fees between 2 and 5 times their normal fees. Then we found that TMA is trying to protect their contractor by claiming increases of this magnitude are common in the Philippines and in the U.S. when providers get paid through third party payers. Given that copays, also increase 2 to 5 times under this ruse and that provider fees are massively higher than what are usual and customary it appears TMA reneged again. Their abrupt turn-a-round in calling this fraud is amazing also. See When is Fraud Really Fraud. Also see Policy Reversal Evidence and Alert: Deliberate Overcharges under the Demonstration (Closed Network) and Policy Reversal Evidence and The Resurrection of Health Visions under the Guidance of TRICARE and their Contractor.

4. TMA said, “You will not have to file claims for medical care received by an Approved Provider.” However there are exceptions which they also reversed policy on. Originally when questioned, ISOS stated that hospitals were required to obtain all required supplies during an inpatient stay, see Policy for Required Outside Purchase. Later they reversed that policy essentially saying if the hospital didn’t want to purchase the item, was out of stock or the item wasn’t stocked by the hospital the patient would be required to go out and obtain the item, pay for it and file their own claim. If the item is available from an approved supplier then you must purchase it from them. Otherwise the supplier must be certified and you will need to request a waiver or be prepared to not recover one centavo. This cost can run into the thousands of dollars so take sufficient cash with you. See Clarification on External Purchase of Hospital Supplies While Receiving Inpatient Care.

5. Remember this promise? “You [beneficiaries] will be responsible for your deductible and cost shares, but you will not be required to make up-front payments.” The majority of specialty providers including anesthesiologists, see Availability of Services above, are not approved and there are blanket waivers for them. That means in all of these cases you will have to make up-front-payments and you will have to break out the local global bill in accordance with the U.S. billing standards and cost the procedures before you can file the claim.

6. Let’s consider a recent additional policy change that we call “Cherry Picking”. I hate to be redundant but again let’s review what TMA promised, “ You will not have to file claims for medical care received by an Approved Provider.” As of now that has all changed. You see TMA is allowing approved providers to decide which procedures they will provide and process claims and which they will require you to pay for up front and file your own claims. The first exception came when TMA admitted that their CMAC is outdated and does not reflect the local usual and customary fees charged everyone else. So they officially sanctioned St Luke’s, an approved provider for outpatient services, to force beneficiaries to pay up front for PET Scans and then file a claim. They even admit in writing that they will not reimburse the patient for a significant portion of the cost. This opens the door for any provider to decide he doesn’t feel he will make enough based on the CMAC and demand payment up front for those procedures. For example surgery, cataract removal etc. See The Demo; Best of all possible worlds and the worst of all possible worlds.

Considering the above, we feel the second major criteria under access to care, Affordability of Services, is somewhat of a failure due to so many exceptions to the claim that beneficiaries will not be required to make up-front payments. But because most inpatient stays, at least the hospital portion, currently still fits their claim we give them a grade of C- in this area.

Physical Accessibility of Services

1. There are two criteria that are generally considered under this area; appointment waiting times and travel times and both well defined for TRICARE Prime. When they did their first presentation, ISOS and TMA clearly had no idea how the health care industry works in the Philippines. In their presentation they provided a step by step process to obtain care. Step 1 was to find an approved provider. Step 2 was to make an appointment. Step 3 was to arrive at the time of your appointment. Obviously both TMA and ISOS missed the boat somewhere along the line. There is not one beneficiary in the Philippines that has seen at least one provider who doesn’t know that the vast majority of providers do not make appointments; it’s a show up and wait in line process and the wait can be hours. Obviously we cannot use the TMA appointment time criteria to judge the success of the program but this did show just how little preparation TMA and ISOS did before they ventured into this experiment. This one blunder clearly demonstrated that TMA’s claim, as stated in the Stars & Stripes article Changes to Tricare come under fire in Philippines, that they considered our input is clearly more propaganda to try to make themselves look competent.

2. The second criteria of travel times are relevant however and there are major issues in this area and in particular in Manila where it turned out and contrary to their claims only one hospital was approved for inpatient care. TMA defines acceptable travel times from your home as 30 minutes for Primary Care and one hour for Specialty Care. However when the issue of these travel times was addressed by a beneficiary in the above article TMA ignored the obvious and instead said, “Travel times have been considered in the recruitment of providers,” Tricare spokesman Austin Camacho wrote. “Beneficiaries may choose to drive to see approved providers but because it is locality based, four- to five-hour drive times are not required.” This was an obvious attempt to beg the question which TMA and ISOS are so good at. The reality is that travel times of 30 minutes for primary care is a pipe dream for the majority of beneficiaries under the Demo and one hour for Specialty Care is also problematic for many. See Metro-Manila Map.

Some typical one-way travel times based on average traffic conditions.

  • Northern half of Metro Manila to Makati Medical Center – 1 to 2 hrs by POV, 2 to 3 hrs by jeepney and bus.
  • Southern end of Metro Manila to Makati Medical Center – 45 minutes to 1.5 hrs by POV, 1.5 to 2 hrs by jeepney and bus.
  • Angeles to AUFMC – On average 30 minutes to 1 hour depending on subdivision.
  • Angeles to Sacred Heart – On average 45 minutes to 1.5 hours depending on subdivision.
  • Those living slightly north of Angeles in the Mabalacat area, add 30 minutes to the above times.

(Because the two St Luke’s outpatient facilities offer at best a single provider that might be considered primary care we did not consider travel times to them as they are essentially non-players.)

3. Another area of concern that is not addressed by TMA’s standards, because they are only concerned with the U.S., is parking. Parking at Makati Medical Center using the parking facilities can add 10 – 20 minutes to the above times. At AUFMC the traffic is always congested and parking anywhere around the hospital is restricted to employees or customers of nearby businesses. This leaves a commercial parking lot behind the hospital which also offers limited parking and is often full which requires one to drive around the lot for 15 – 20 minutes hoping to get to a newly opened slot as someone leaves. For AUFMC consider adding on average 15 minutes to the times above if using a POV.

Considering the above, we feel the third major criteria under access to care, Physical Accessibility of Services, is a significant failure because the majority of beneficiaries will have excessive travel times. We give them a grade of F in this area.

Acceptability of Services

The approval of the services depends on a lot of factors involving the social and cultural barriers that drive acceptance. In other words acceptance depends a lot on how people perceive the services they can receive. Perception includes how they feel about the organizations such as TMA, ISOS and their front Global 24 and of course the hospitals and providers that make up the limited closed network. Perceptions of quality, reliability, access and believability will also influence how well the services are accepted.

We are aware that some individuals are willing to overlook or excuse the shortcomings citing the other benefits of the program and therefore find it acceptable. Others are more neutral while others hold a more negative attitude towards the services.

A recent survey of retired military in the Philippines asked multiple questions about the Demo. The last question asked retirees how they rated the Demonstration compared to other TRICARE programs. The results are below.

Survey

Considering the above, we feel the fourth major criteria under access to care, Acceptability of Services, is a pretty much a failure based on how retirees responded to the survey question above. We give them a grade of D in this area.

Quality of care

The TMA likes to claim, “You will have access to providers who deliver high-quality medical care.” But like most of TMA’s claims it is a hollow and unsubstantiated claim. Multiple requests to TMA and ISOS asking for the criteria used to determine the quality of providers selected for the Demo met with the typical run-a-round. The truth is, other than the providers being licensed in the Philippines, there are no quality checks and TMA and ISOS know this. See Demonstration Project/Closed Network Provider Quality Standards and The Real Story on Quality of Care under the Demonstration for a more detailed explanation and the proof. This lack of quality checks while forcing beneficiaries to see extremely limited numbers of providers is nothing more than a recipe for disaster and will ultimately result in harm or loss of life or limb and we have already seen the start of this.

  • Absence of ability to choose doctors – By forcing beneficiaries to see a single doctor, within a specialty, TMA has violated their own policy, “You have the right to: Your choice of health care providers.
  • Absence of ability to obtain provider credentials – DoD Instruction 60000.14 states, “Patients have the right to receive information [professional credentials] about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services.” Both ISOS and TMA have refused to provide this information and told us their contracted providers are not obligated to provide them either.
  • Room accommodations – TMA states if a local hospital states room accommodations are Semi-Private, regardless of the number of beds and individuals sleeping in the room or how many people use the facilities, TMA will require we use those facilities. See What Constitutes a Semi-Private Room under the Demonstration? for a detailed explanation.
  • Disposal of hazardous waste – Approved hospitals have violated local policy on disposal of waste and demanded that a patient’s family come to the hospital and take hazardous waste removed from a loved one home and make their own arrangements for disposal.

Considering the above, we feel Quality of Care is also pretty much a failure. Because they at least require the providers to be licensed, we give them a grade of D- in this area.

Program Changes

One would think that, as the Demo progressed, TMA would strive to make it better for beneficiaries via changes and modifications. The reality is every change so far as been an attempt to keep the experiment from failing, by accommodating providers and at the expense of beneficiaries. These have all been addressed in some detail above so are only mentioned here to put them all in prospective.

  • Pay deductibles and copays upfront – This change was made solely to keep the experiment from failing because providers were not willing to agree to submit claims using a foreign system and used as an enticement and sold out beneficiaries.
  • Allowed and encouraged to overcharge – Another change to try to get the cobbled experiment off the ground. For years TMA has bemoaned the overcharges from local providers but now proclaim them as normal and acceptable practice when dealing with TMA.
  • Pay for your own hospital supplies if the hospital doesn’t want to buy them – Another concession to keep the crippled experiment alive and again at the expense of beneficiaries who were promised they would not have to pay upfront and process claims.
  • Cherry picking of care – Another example and latest attempt to salvage something from the experiment and again at the expense of beneficiaries who again pay upfront and file claims that will not be paid as a large portion of the normal reasonable cost will be denied.

Considering the above, where every change has been a concession to providers to entice or keep them in the program at the expense of beneficiaries we give them a grade of F in this area.

Beneficiary satisfaction

Obviously, based on the recent survey of retirees they are not too happy with the Demo despite what TMA pushes out to Congress and the service organizations.

Let’s look at some of the specific issues:

  1. Fake company used to develop network and train providers. Global 24 was toted to be a local company with expertise in the development and maintenance of Health Provider Networks. Since it is owned by ISOS and came into existence just months before the Demo went live, we hardly believe that is true. See Who or What is Global 24 Network Services, Inc. Really?
  2. Listing of approved providers is not reliable. Providers come and go due to huge errors on the part of the contractor. They appear on one list and disappear on the next only to reappear a few days later. Due to the large number of errors in their database the search engine is unreliable.
  3. Instead of admitting their short comings ISOS insists they do not exist. One example is when multiple people reported that AUFMC was not available 24/7. See Two Words that ISOS Doesn’t Know – Yes and No.
  4. ISOS puts out false information. In December 2012 ISOS announced that the St Luke’s hospitals were signed up as part of the Demo. But wait, it was going to take ISOS 6 weeks to train them so they wouldn’t be available until around February. It turned out they were never going to be available as hospitals but as outpatient stations only; just a minor omission on the part of TMA and ISOS. See The Demonstration Project’s Great Farce Perpetuated by ISOS and TMA.
  5. Claim Issues
  • Failure to reimburse for overpayment of deductibles and copays. We have example EOBs where these overpayments were not reimbursed as promised. On inquiry the beneficiary was told that WPS processed the claim without all the information required and advised them to try to get it back from the provider.
  • Failure to file claims where 100% of cost paid. There is absolutely no incentive or requirement by TMA for providers to file claims when the total cost of care was paid in full due to deductibles. We have multiple examples of care from January that have yet to have claims filed.
  • WPS demanding that beneficiary’s breakout and cost professional care. We have seen multiple letters from WPS demanding the beneficiary accomplish this on Demo claims submitted by the provider but without the proper breakouts.
  • Providers demanding you sign blank claim forms in violation of TMA policy. See Be Very Careful with Your Signature and the Demonstration.

Considering the above examples and the survey results we give them a grade of D in this area.

Provider satisfaction

While ISOS and TMA claim providers are happy as clams we and many military retirees have heard otherwise from both physicians who have not been paid and staff from the hospitals.

In April Baypointe Medical Center (BMC) jumped ship after their board of directors voted to drop the Demo due to non-payment. At least one patient was told he had to pay in full for his inpatient stay and a number of others were turned away for outpatient care. Frewen from ISOS continued to deny there was any rift as did their front Global 24 and while patients were being turned away. After a couple of days of apparent intense lobbying behind the scenes by ISOS the board of directors relented and reinstated the Demo. But for how long is another question.

At the end of May Sacred Heart Medical Center (SHMC) and their physicians announced that as of 1 June they would no longer accept Demo patients due to non-payment of claims. Again after some intense lobbying by ISOS staff the hospital agreed to temporarily continue until the end of July and if the claims were not paid by then they would drop the Demo.

Conclusion

While there are a few bright spots and many inpatient stays are now at least partially covered under the Demo, there are major issues with access to care and overcharges that TMA called fraud for years in the past but are now defending as acceptable practice in an apparent attempt to entice providers. There are also ongoing issues of providers not being paid and mostly due to forcing a counties health care industry to change how they do business to comply with billing standards found only in the U.S.

It appears both the majority of beneficiaries and providers are not happy with this Demonstration so how long it will survive is anyone’s guess.

Experiences

Please report your experiences and examples of over charges and claim denials to USMRoP

Contact us at: us_mil_ret_of_the_pi@fastmail.fm

What’s Next?

As we gather more information from TMA, the contractor and beneficiaries we will continue to send out newsletters but generally not more than once a month.

What we are seeing is rapidly put together policy that then changes within a few days only to be changed once again. These in turn raise new issues or other unforeseen problems surface. To keep up with these we will post shorter topic specific updates and notices on our blog, TRICARE Overseas Philippines Blog. Recommend those interested in keeping informed on the experiment check it frequently or alternately add your email address and click “Follow” about midway down the front page and on the right. This will automatically email you a link to each new entry.

<Archived Newsletters

Previous Newsletters can be accessed by going to U.S. Military Retirees of the Philippines Group TRICARE Newsletter Archive.

Share this newsletter with other beneficiaries

Forward this newsletter to others you feel might benefit from them so they can sign up as well. If you represent an RAO or service organization let your members know so they can sign up. Sign up link

Leave a Reply

Comment validation by @