Tricare’s new “closed network” for Tricare Sub-Standard Philippines;

Tricare’s new “closed network” for Tricare Sub-Standard Philippines; What we know and how it will accelerate the death of U.S. Military retirees By Kenneth J. Fournier (Kennyfour09@yahoo.com.ph)

In an effort to cause more pain and suffering upon the U.S. Military retirees living in the Philippines, Tricare is now poised to implement, a new, extremely restrictive “closed network” for Tricare Sub-Standard in the Philippines. On top of tricare’s current inability to provide the promised, and legally mandated, medical care to retirees including the slow payment of claims, a requirement to use only Tricare certified providers listed on a provider list that is absolutely impossible to use, mandatory requirement for Philippine providers/retirees to learn a U.S. unique medical billing and pricing system, (which no other country in the world uses), requiring not only proof of payment for medical care but also demanding, (under threat of non-reimbursement of claims), that we prove the source of the funds used to pay the provider and a Philippine specific reimbursement rate system that ensures underpayment of most claims. Now Tricare is implementing a “closed network” system for the Philippines. So, let us examine what this new system is. Since Tricare refuses to answer questions about this new system, we are forced to piece together information we have gleaned from official Tricare documents, slips of the tongue by Tricare officials and rumors from employees working within the Tricare “family”. We first became aware of the “closed network” through pure accident while researching some other Tricare Sub-Standard in the Philippines issues. This “find” was in the form of a power Point presentation, (see Power Point, slide 17 athttp://db.tt/t9cyCoJ), which was done by the Tricare Communications & Customer Service section at a C&CS conference on 5 August, 2010. The power point states: • Establish a Closed Network in the Philippines (three year demo) • Overseas contractor will establish an approved list of providers and inpatient facilities • Providers will be selected based on quality, accurate claims submission, and cost • Waivers will be provided for emergency situations • Providers who agree to join the network will be reimbursed at the lower of the usual and customary charges and the established fee schedule • Providers may be terminated from network without cause or appeal • TMA will evaluate project progress and may seek permanent authority to continue program Upon finding this Power Point presentation, I sent an email letter on 18 January, 2011 to Tricare’s Deputy Director, RADM Christine Hunter, asking for the details of the “closed network”. The following is an excerpt of that request. (The full letter is available here:http://db.tt/MQYmKkd ) “This “closed network” is not defined in the report with any specificity. I request the following questions be answered;

1. In what exact areas will the “closed network” be established? 2. If, as we have been informed, the “closed network” will only be established in Manila, Angeles City, (Clark), and possibly in Subic, (Olongapo), how will beneficiaries residing in areas outside of the “closed Network” be accommodated? 3. What provisions will be made to include providers that beneficiaries are already utilizing, (and are comfortable with), within this “closed network”? 4. Will the providers be required to participate on all claims? 5. If the provider will not be required to participate on all claims, what training will ISOS/TMA provide to the provider in order to ensure that medical records, receipts and narratives will be acceptable to WPS for “FULL PAYMENT” of medically necessary care? (This is asked because currently claims submitted by beneficiaries are being denied or delayed due to WPS’s insistence that the provider use CPT coding and individually price all medical care even though this is not the local and customary practice. Philippine providers use “global billing” practices, as most OCONUS countries do). 6. What provisions are made for a beneficiary to request a provider be included in the “closed network”? 7. When is the anticipated, (or target), start date for the “closed network”? 8. Will this “closed network, three year demo” be published in the federal registry?

Lastly, in compliance with the TMA transparency policy, I request a full and complete copy of the “closed network in the Philippines, (three year demo)”.This request is in addition to the answers to the above questions.”

RADM Hunter sent my request to Capt. John Rothacker, Executive Director of Tricare Area Office-Pacific and apparently instructed him to respond to my request. Capt. Rothacker sent me this email on 19 January, 2011; “Chief Fournier,

I am the Executive Director of TRICARE Area Office Pacific located on Okinawa. I wanted to let you know that RADM Hunter has received your email and tasked me in drafting the response requested. I have acknowledged the request and am working on your issues and while I cannot give you a specific date for reply, please know that we take your issues seriously and will respond promptly.

After numerous requests for follow-up to Capt. Rothacker, I was advised to do a FOIA request for the information. Thus, attempts to gain an insight of this “closed network” were stalled for 5 months. However, some slips of the tongue have occurred and we have been able to glean some of the details of the “closed network”. The following is what we know from Tricare personnel; 1. According to Capt. Rothacker in a response to another retiree, the “closed network” will be established in Manila, Angeles City and Olongapo City. All retirees/beneficiaries must use only the providers that are part of the “closed network”. 2. According to Capt. Dianne Aldrich, Tricare Area Office Pacific, Hawaii Satellite for Remote Pacific Islands, the statement of Capt. Rothacker are basically correct. However Capt. Aldrich refused to elaborate on the details and could/would not explain how retirees/beneficiaries residing outside of the Manila/Angeles City/Olongapo City areas would be accommodated for their medical care since many retirees/beneficiaries reside hundreds of miles from the listed “closed network” areas and most must take air transportation to get to those areas. 3. According to Capt David Metzler, former acting Executive Director, Tricare Area Office-Pacific, in an email to a retiree in August 2009, (it appears that TMA took Cpt. Metzler’s “FIX” and ran with it); “I know you are as frustrated as I am. My fix for the situation is to wipe the slate clear of all providers and go in with a limited, closely scrutinized, stringently supervised closed panel of providers. No additions, no changes, no substitutions allowed. This would stop the companies that are defrauding the U.S. Government and hold the providers in the closed network to those very few that we can confirm are legitimate. The problem with doing that is that the retirees and beneficiaries would be up in arms immediately because we are limiting their choice of providers and making them travel great distances to see only those we approve! As you can see, we are damned if we do and damned if we don't. We can't please everyone and so the middle ground is pleasing no one.”

4. The retirees/beneficiaries residing in the Philippines are widely distributed around the over 7,000 Islands that make up the Philippines. The following map pinpointed the areas that Health Visions Corporations had set up hospitals, clinics or contracted with local hospitals and clinics to care for Tricare eligible beneficiaries during the period of 1998-2006, (note HVC was closed down because of fraud on the Tricare program);

Each dot on this map represents an area where pockets of retirees/beneficiaries reside, (and this was only where HVC had facilities/contracts. There are hundreds of retirees/beneficiaries whom are not represented on this map).

Notice that some of the pockets are in the southern most areas of the Philippines as represented by the areas in Mindanao. Other than the retirees/beneficiaries residing in Manila/Angeles City/Olongapo City, (about 40% of retirees/beneficiaries), all others reside more than 2 hours from the areas that the “closed network” is to be established. Most retirees/beneficiaries live on Islands that require a 24 hour ferry ride or a one-two hour airplane ride to get to the “closed network” areas.

If, (and all indications point to this being the case), the “closed network” is implemented in only the Manila/Angeles City/Olongapo City areas then thousands of the estimated 12,000 retirees/beneficiaries living in the Philippines will be required to travel long distances to avail of their Tricare benefits.

Since Tricare regulations prohibit reimbursement of travel, lodging and food expenses as a Tricare Standard benefit, what retiree/beneficiary will spend the hundreds of dollars required to go to the “closed network” area to see a doctor for a routine office visit and who is going to wait until they can travel to the “closed network” area to get urgent, but not emergent care.It will be cheaper for them to purchase their own care, (in essence denied access to their earned benefit), and would result in TMA being able to show additional savings to justify the continuation of the closed network, (at the expense of retirees/beneficiaries being denied reasonable access).

The planned “closed network” must be bad policy because Tricare refuses to discuss it with us. If it was a positive change in policy, Tricare would be touting it loudly and often in all their publications and briefings. The lack of willingness to provide a “sneak peak” at the “closed network” says; This will cause extreme pain, loss of reimbursement for legitimate medical care and can be expected to cause multiple deaths of beneficiaries due to lack of access to medical care that is an earned benefit and legally required of Tricare to provide.

Tricare has routinely implemented policies on the retiree/beneficiary community in the Philippines in “SECRET”, refusing to provide information to the retiree/beneficiary community in advance of changes and, after changes are implemented, refusing to discuss the flaws that retirees/beneficiaries present to them.

We will not wait until this new “closed network” is implemented to, as Nancy Pelosi famously said, “find out what’s in it”.

So, should retirees/beneficiaries die because Tricare wishes to take an easy way to out of solving the “fraud” problem that they helped create with their poorly thought out policies? The option that the DODIG, Defense Investigation Service and the Assistant U.S. Attorney for Wisconsin told Tricare to implement is a PPO, using a local based health insurance company such as Blue Cross of the Philippines. (See article by DCIS Special Agent Daniel Boucek for details,(starting on page 23), http://db.tt/o5hAu1B).Tricare still refuses to contract for a PPO, which would save anywhere from 5-10 million dollars, virtually guarantee access to all retirees/beneficiaries and totally eliminate the fraud potential. (See PPO discussed at http://db.tt/dNCHAMb for details).

Instead, Tricare will implement a restricted “closed network” that will be limited to 3-4 major cities and will deny reasonable access to thousands of retirees who sacrificed years in service to the United States and earned their Tricare benefits. Tricare is required to provide medical care to all retired military members and their dependents. Limiting access, as the “closed network” will do, is a violation of the law and the promise made by our government.

The Federal government is going to disappoint every beneficiary of government benefits, whether those benefits are earned, or unearned. There is just not enough money to pay for it all.

The solution, for better or worse, is in the article: “It will be cheaper for them to purchase their own care”.

Everyone, to the extent that they rely on the government for a check, or a benefit should pay attention.

Wait retired military personnel who CHOOSE to live in the Philippines to take advantage of the low cost of living want the US government to provide them with first class medical care while they do it. No way dude shag your ass on a flight back stateside and pay your taxes and check your butt into the VA hospital of your choice. The era of I want my cake and eat it too must come to an end.

Sorry, I did not understand your question.I can tell you that Tricare Management Activity, (TMA, also known as just Tricare), is in the process of implementing a Champus Maximum Allowable Charges, (CMAC), on Mexico and Costa Rico. The new CMAC will be based on a WORLD BANK Purchase Power Parity, (PPP), that takes an average of the cost of goods and services and then compares that average to what $1.00 would buy in that country vs. the cost to buy the same goods or services in the US. Currently the Philippines and Panama ae under this PPP based CMAC.

Unfortunately,when you use an average, you get half of the cost exceeding the arbitrary cap, (CMAC), and half being lower. We are finding that most of our reimbursement claims are less than the actual cost, (minus our co-pays), thus we lose thousands of dollars on our medical care. TMA refuses to adjust the CMAC or to even discuss it with us.

I do believe that the “closed network” will be coming to most countries where there are large retiree populations. The effect of it will be to decrease the Tricare cost artificially by denying care to retirees unable to go to the areas where the closed network is established. This will show up as a “cost savings” report to Congress, but it will not be a legitimate cost savings, instead it will be a denial of access cost savings.

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