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CPT Codes & Pricing

CPT Codes & Pricing

Status as of 19 DEC 2012


An issue that I have discussed at length in the past, and for which you have seen fit to refuse to resolve, has started to become a major problem for Tricare Standard patients/beneficiaries in the Philippines.

Due to TMA’s and ISOS’s refusal to provide the CPT codes and pricing, (CMAC), for procedures, (office visits, ancillary fees, x-rays fees, imaging fees, out-patient facility fees and specialty test fees), from the fee schedules that are required by Philippine law for the providers to post, beneficiaries are starting to receive request, (at a higher rate than before), demanding the CPT codes for procedures performed, or, a description of the procedure using US medical insurance compliant terms.

We are at a loss to understand how you can expect a beneficiary who must file his own claims under the Tricare Standard in the Philippines to know what the CPT codes are for a procedure or the correct US medical term when these CPT codes and/or medical terms are not known by Philippine providers. We also do not understand how you can expect a local Philippine provider to dramatically change the methods that they write their billings for services rendered when, according to the Tricare Manuals, and the Tricare providers handbook, foreign providers are told to bill IAW local customs.

From the Tricare Host Nation Provider Handbook, Tricare Area Office-Europe, February 2008;

Billing & Claims Filing

Medical Billing

Compile and price medical billing according to the generally accepted

standards of the country in which you practice. Bills should normally be issued

within 90 days of the date of care and submitted to the claims processor within 12

months of that date. At a minimum, bills must include the following information:

Your complete physical and billing address, in letterhead format.

Itemization of the costs and services provided.

Preferred provider’s identification number.

The patient’s name and date of birth.

The sponsor’s social security number

The patient’s diagnosis.

The date the care was provided.

I realize that this is the Europe edition of the handbook, but I selected it in order to illustrate that your current policies for the Philippines conflict with the policies for all other TOP foreign nation providers. It is highly unlikely that this policy has changed and that TMA’s policy is now that foreign providers must use the US CPT codes, US medical terminology or US standards of medical care.

In the Philippines, you are demanding that providers write their billings for services in the exact manner that US providers write their billings. US providers have had decades of experience with the US Government and Insurance carrier’s requirements that specific phrasing and terminology be included in a provider’s billing in order to be paid for the services rendered.

In Europe you accept the local billing custom and then, at WPS, your claims processors assign one CPT code that, in their opinion comes closest to the procedure described in the provider’s narrative of services. The claims processor then attribute the full, 100%, billed amount to that one procedure and pays the claim accordingly.

In the Philippines, (and to a lesser extent in Panama), your claims processor reads the invoice/narrative and makes a decision of what CPT code applies to each listed procedure. That “guess” is then used to determine what amount the Philippine specific CMAC allows, and that is the amount allowed on the EOB.

Since Philippine providers do not use the US CPT codes, and in many cases the US terminology, the beneficiary is provided with a bill from the provider that does not, in most cases, translate directly to the US CPT codes. The claim processor does not have the medical billing training that would be required to cross-over the local Philippine medical terminology into US terminology, which would then allow for the assignment of the appropriate CPT code.

This results in the claim being underpaid or denied because the beneficiary cannot convert the local bill/narrative into the demanded CPT code. Providers, who have attempted to participate on Tricare Standard claims have found that their claims were grossly underpaid, denied or they were confronted with an unachievable task of responding to a request for additional information which they could only respond by re-submitting the original documentation for the claim. WPS rarely gives any guidance as to what is being requested in the request for additional information, so the provider throws his hands up in the air and ceases participation on Tricare claims. (Just look at what happened with The Medical City when they attempted to participate on Tricare Standard claims. They lost over a million dollars because of their inability to convert local medical procedure into US CPT codes).

TMA and ISOS realize that converting local medical procedures and narratives into US CPT codes is beyond the abilities of the local providers, why else would they tell their TGRO Prime contracted providers to provide an itemized bill and narrative for care provided to TGRO Prime beneficiaries and that ISOS will convert the local billing and narrative into the appropriate CPT codes. Below is a copy of this instruction to TRGO prime providers, (source, ISOS website, Provider section, provider handbook, section 5, page 46; accessed 19 December, 2012)

Notice the section above it clearly states that ISOS will translate the treatment details from the invoice into CPT codes. This clearly acknowledges that foreign providers will be unable to convert local billings/narratives into the WPS required CPT codes, and thus, ISOS must do this function for the provider.

However, when it comes to Philippine Standard beneficiaries and participating providers, this assistance is not available, and without this assistance, the beneficiary or provider is underpaid or denied payment simply because the WPS claims processor MUST, (under the Tricare in the Philippines policies), convert every procedure into the appropriate CPT codes, (which they are not able to do because they do not have medical coding/billing degrees, (the medical coding/billing field requires a 2 or 4 year college degree and ongoing continuing education along with annual conference attendance)).

There are two different solutions to this problem;

1. Scrap the Philippine specific CMAC and pay as billed charges, (as is done in every other overseas location), or

2. Acquire the medical procedure fee schedules for all offered services from Makati Medical Center, St. Luke’s Medical Center, Quezon City/Global City and The Medical City. Convert all of those procedures into CPT codes and determine the maximum that Tricare will pay for each procedure. Provide that listing of CPT codes and pricing to Philippine providers and beneficiaries and instruct WPS to use these list of procedures for payment purposes.

Under the TGRO Prime, you already require the TRGO Prime Providers to submit their fee schedules, (source, ISOS website, Provider section, provider handbook, section 3, page 24, “How to Become an International SOS Network Provider”; accessed 19 December, 2012); Examples of credentials include a copy of professional license, proof of malpractice insurance (where applicable), fee schedules and other information.

We realize that TMA will not curtail the Philippine specific CMAC, thus, the only option available is option #2. Failure to do this will result in even fewer providers willing to participate on Tricare claims, more loss of legitimate beneficiary reimbursement and the failure of the Philippine Demonstration Project.

Why will refusal to implement option #2 result in the failure of the Demonstration Project? Simply because ISOS has stated, in the meeting conducted on 30 and 31 October, 2012, that they will not assist providers, (Demonstration and non-Demonstration providers, nor beneficiaries), in determining the appropriate CPT codes to use on claims for medical care.

Once the Demonstration Providers realize that their claims are being denied or paid at a level less than they charge their Filipino patients, (or they encounter recurring request for additional information), they will refuse to participate in the Demonstration Project.

There will be a mass exodus from the Demonstration project because, when one Approved Provider starts to encounter underpayments or denied claims, he will tell his colleagues and they will quickly cease participation.

If, by some chance, TMA and ISOS decide to offer the Approved Providers the same level of claims perfecting assistance as is provided the TGRO Prime providers, we will find out about it and will immediately ensure that our elected officials and the media become aware of the violation of our constitutional rights for fair and equal treatment under the law.

Please take option #2 and quickly implement it. It is the best option available to you if you do not wish to scrap the Philippine specific CMAC, (which we believe should be the ultimate fair and equal solution).

Kenneth J. Fournier, MAC, USN, (ret)

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