Skip to comments.Is this the prelude to ObamaCare (TRICARE in the Philippines)
Posted on 10/11/2012 5:16:25 AM PDT by usnavy_cop_retired
Is this the prelude to ObamaCare (TRICARE in the Philippines)
If you are covered under Medicare and live in the City of Los Angeles you will soon be required to select a doctor from a small list of doctors who have agreed to Medicares new list of preferred providers. The list will have only one to three doctors in each of the 18 major specialties. Along with that, you will only be able to be treated at one hospital in the Los Angeles City area, (probably located in mid-town), and you will also be restricted to a small list of clinics, laboratories, physical therapist and dialysis centers.
If you decide to use a doctor, hospital or clinic that you have been using for years, and is close to your home, knows your medical history and you are comfortable with; you will pay 100% of the fees. Medicare will not pay for your medical care.
And worse, even if you do not live in Los Angeles but use a doctor, hospital or clinic in Los Angeles which is not on the Medicare preferred provider list, you will still pay 100% of the medical bill because you did not use one of the Medicare preferred providers.
You may be saying that this is not true. Well you are correct. Medicare is not planning on doing such a horrible thing to Medicare patients, but, guess which government agency is actively putting in place such a program under the guise of a Demonstration Project. Yep, its the Department of Defenses TRICARE Management Activity, (TMA).
Starting 1 January, 2013 TRICARE will put in place a mandatory program to do just what I described above. This Demonstration Project was planned and is being implemented by TMA without providing the opportunity for U.S. Military retirees and their dependents living in the Philippines to have any input on the project, and when we accidently got wind of it two years ago, TMA refused to answer our questions or to consult with us. All attempts, even numerous written requests sent directly to the TRICARE Director, RADM Hunter, were deflected, ignored or sent into a black hole.
Since TRICARE has seen fit to ignore all of our inputs or to consult or hold a dialogue with us, we are going public with our complaints.
Over the last several years we have attempted to explain our complaints with the TRICARE Overseas Program, (TOP), Philippines, (which is under specific, non-published rules that do not apply to TRICARE Standard beneficiaries in any other country worldwide). We have found, on numerous occasions that TRICARE Management Activity, (TMA), has attempted to respond to Senators, Congressmen, Military Service Organizations and Journalist concerning our complaint by discussing areas that have nothing to do with the subject matter of our complaints. This tactic has worked very well with members of Congress and of the Press, resulting in us spending a lot of time to attempt to correct the record. Based on our past experiences, we are going to use the actual text of the rules and regulations and then present our complaints and arguments. Hopefully this method will eliminate the double speak and may elicit honest discussions of the issues.
The following chapter and section of the TRICARE Operations Manual was downloaded from the TRICARE website and is the latest change to the manual, (21 September, 2012).
We will print the original paragraph and then provide our comments and complaints so that all who read this will have the proper context of the points and arguments that we are making. The first section will be a background of the current issue concerning TOP Philippines. Our comments are preceded by an *
Over the past several years TMA has attempted to fix the TOP Philippines by imposing numerous special rules on the beneficiaries, (approximately 11,000 in total), and providers in order to curtail the TRICARE fraud which the DOD Inspector General laid directly at the feet of TMA and their contractors, (Wisconsin Physician Services, (WPS), and International SOS, (ISOS)), for their failure to respond, for years, to the numerous beneficiary warnings of fraud by certain providers. (See DODIG report D-2006-051).
Excerpt from D-2006-051);
"Audit Response. The Assistant Secretary of Defense (Health Affairs) comments are responsive. However, we caution TMA from relying on criminal proceedings or recommendations from DoD OIG to initiate administrative sanctions. Aggressive pursuit and implementation of timely administrative controls and sanctions are needed. TMA used data provided by the DoD OIG to propose excluding Company A from the TRICARE program in November 2005. TMA had access to the data for years and could have used their administrative sanctioning authority. Following receipt of allegations of abuse from TMA and beginning in December 2000, DCIS repeatedly advised that TMA take immediate actions that would prevent fraud without regard to the impact on the investigation."
"Moreover, TMA was aware as early as September 2002 of the supplemental plan Company A offered that apparently waived required beneficiary cost shares. On that factor alone, TMA could have taken action against Company A for violating the anti-kickback statute. Further, there were numerous beneficiary allegations that Company A billed for services not rendered, or not medically necessary, and grossly inflated TRICARE claims."
*We will not attempt to rehash the battles of the past 8 years here, nor will we attempt to discuss other issues with TRICARE in the Philippines that are still ongoing complaints. The focus of this article will be limited to the Demonstration Project.
In January, 2011 we found, on the internet, a Power Point presentation that the TRICARE Communications & Customer Services Division, (C&CS), presented at a C&CS conference on 5 August, 2010 in which they outlined the Demonstration Project. (http://db.tt/t9cyCoJ) (see page 17). We immediately requested that TMA provide answers to numerous questions that we had based on the outline and requested that TMA engage in a dialog with us so that any potential problems with the Demonstration Project could be worked out prior to implementation. TMAs response was that the Demonstration Project had not been given final approval by TMA and DOD and therefore TMA would not discuss the program with us.
In 2011 TMA announced in the Federal Register, (Federal Register / Vol. 76, No. 188 / Wednesday, September 28, 2011 / Notices 60007), that TMA was going to do a Demonstration Project in the Philippines. There were no public comments requested for this Demonstration Project.
The Demonstration Project was published in the TRICARE Operations Manual on 21 March, 2012 and is included below.
"TRICARE Operations Manual 6010.56-M, February 1, 2008 Demonstrations
Chapter 18, Section 12. Department Of Defense (DoD) TRICARE Demonstration Project for the Philippines"
"1.0 PURPOSE This demonstration will allow the DoD to determine the efficacy and acceptability of an alternative approach to the delivery of health care in the Philippines. The DoD TRICARE Demonstration Project for the Philippines (hereinafter referred to as the demonstration) will enable DoD to determine whether it is possible to control costs, reduce aberrant billing activity, and eliminate balance billing issues while providing high quality, safe health care to TRICARE Standard beneficiaries residing in the Philippines and receiving care in designated demonstration area(s). This will be accomplished by the establishment of a dedicated list of providers who agree to comply with certain requirements and business processes as outlined below."
"Although the number of TRICARE beneficiaries residing in the Philippines has remained relatively constant over time,"
*The latest estimate of beneficiaries, (retirees, dependent spouses, dependent children, widows, widowers and TRICARE for Life beneficiaries), in the Philippines is 11,000.
"there has been a significant increase in the amount billed for health care services. Administrative controls and the implementation of a government-directed foreign fee schedule have been only partially successful in containing costs. Additionally, certain billing practices in the Philippines have resulted in beneficiary dissatisfaction and excessive out-of-pocket expenses due to balance billing."
*Due to the Philippine CMAC, which has not been updated since inception for in-country medical inflation, (which is about 30% since 2007), and for currency exchange rate fluctuations, (which has caused a 15% loss of purchasing power since 2005 when the World Bank PPP study that the CMAC was based on was published), it is no wonder that there has been a significant increase in the amount billed for health care services. (See Champus Maximum Allowable Charge for a complete explanation of the inflation and exchange rate issue. Source; http://TRICAREoverseaswallofshame.webs.com/apps/faq/#anchor-2-0 ). (The Philippines and Panama are the only countries where TRICARE beneficiaries and providers are only paid based on a CMAC, which is a percentage of the average U.S. CMAC. For the Philippines, the U.S. average CMAC is multiplied by a factor or .52%. TRICARE beneficiaries in all other countries are paid on an as billed basis, thus, whatever the provider charges will be paid in full).
The only cost savings that TMA is realizing is the amount that beneficiaries must absorb over and above the CMAC. Philippine providers charge the same prices for their services to TRICARE beneficiaries as they do to Filipinos. Since the CMAC has not been adjusted for Philippine inflation and currency exchange fluctuations, the cost of the medical care has exceeded the CMAC. The beneficiary still must pay the provider the going rate, but is reimbursed at the lower CMAC rate. For example; a Philippine provider charges 600 pesos, ($14.29), for a routine office visit, however, the CMAC allows only $10.25 for that same office visit. Thus the beneficiary is absorbing $4.04 of non-allowed cost and his 25% co-pay based on the $10.25 allowed by the CMAC, ($2.56), for a total out of pocket cost to the beneficiary of $6.60, (46% of the billed charges).
In the TRICARE Manual statement above, TMA states that: Additionally, certain billing practices in the Philippines have resulted in beneficiary dissatisfaction and excessive out-of-pocket expenses due to balance billing. This statement is a straw man. Balance billing is a unique U.S. legal concept. The U.S. laws for Medicare and TRICARE, (and almost all government run health care), prohibits the provider from going back to the patient to collect the portion of the billed amount that the government denied payment for. In other words, if the provider billed TRICARE for $100 for a procedure and TRICARE determined that it was only going to pay $75 for that procedure, the provider is prohibited, by law, from going to the patient and demanding the $25 differential.
Philippine providers are not controlled by U.S. law and could care less what the TRICARE CMAC is. The provider has a fixed amount that he charges all his patients for his services and expects to be paid that amount. Since TRICARE beneficiaries must pay up front for medical care and then file a claim for the care with WPS, (Wisconsin Physician Services, the TRICARE claims processing contractor), the difference between what the beneficiary paid the provider and what the TRICARE CMAC is, is the responsibility of the beneficiary. The beneficiary cannot go back to the provider and demand the difference be refunded to him, and TMA knows this fact.
"Beneficiaries in the Philippines are frequently required to pay the provider or facility at the time services are rendered, and file their own claims for reimbursement. Since TRICARE reimburses these claims based on the fee schedule, a beneficiary may incur excessive out-of-pocket expenses (in addition to their normal cost shares and deductibles) if the billed charges exceed the fee schedule amount."
*Again, this is a straw man as explained above. TMA, on numerous occasions has been presented with the solution to this problem.
First, the CMAC needs to be set in Philippine Pesos instead of in U.S. dollars. That step alone will establish a constant value for the services provided since the rate is not subject to currency exchange rate fluctuations.
Second, the CMAC needs to be adjusted annually for the Philippine inflation rate. Currently the only inflation adjustment is the Medicare annual adjustment which is not reflective of the Philippine medical inflation rate.
Third, TMA must do what they have refused to do for the past 10 years, which is to conduct a prevailing rate survey for the Philippines, preferably a prevailing rate for Metropolitan areas such as Manila, Cebu and IloIlo City, and then a prevailing rate for the provinces, (which have a lower medical cost factor).
On several occasions over the past year we have provided TMA, ISOS and WPS senior personnel with a print out of the fees charged by several major hospitals in the Philippines, (Metropolitan areas, medium sized cities and Provinces), all of these fee schedules are available to ISOS, (International SOS, the TRICARE contractor for all Tricare programs outside of the U.S.,), upon request from every provider that they certify. These are the fees charged by Philippine providers which are required by Philippine law to be posted at all facilities. They include the hospital bed rates, operating room use fees, hospital staff physician fees, emergency room use fees, (by the hour), laboratory fees, (broken down by procedures), x-ray and CT scan fees, (broken down by procedure) and all other billable charges. All medical institutions, (hospitals, laboratories, dialysis centers etc.), must post their fees for potential patients to be able to compare prices.
Even though these fee list were given to TMA/ISOS/WPS personnel with a request for them to supply the CPT codes, (because Philippine providers do not use the unique U.S. CPT codes and medical terminology in the Philippines is not always the same as in the U.S.), and TRICARE CMAC for each procedures, they have yet to provide us with the requested information and have not incorporated the actual prevailing rates for the Philippines into the CMAC. So, the opportunity has been given to TMA to fix the issue of the billed charges exceeding the fee schedule, but obviously they do not wish to do that. They would rather be able to tout savings by forcing the beneficiary to absorb a larger portion of the medical bill.
"3.1 Approved (Demonstration) Provider"
"A provider who agrees to accept TRICARE reimbursement at the lesser of billed charges, a negotiated reimbursement rate, or the government-directed foreign fee schedule as payment in full; agrees to submit claims to the TRICARE Overseas Program (TOP) contractor on behalf of TRICARE beneficiaries; and agrees to collect only applicable cost-shares and deductibles after receipt of the TOP Explanation of Benefits (EOB). In addition, all approved demonstration providers must comply with the on-site verification and provider certification process described in Chapter 24, Section 14 and the certification and credentialing requirements outlined in Chapter 24, Section 4; 32 CFR 199.6; and the TRICARE Policy Manual (TPM), Chapter 11."
*The Demonstration providers will be required to accept only what the TRICARE CMAC allows for their services. Since the CMAC is already lower that the normal fees charged by most quality providers, we anticipate that few providers will agree to become a contracted Demonstration provider. (The population of the Philippines, (2011), is 94,852,030. TRICARE beneficiaries, (11,000), represent 0.000116% of the population. A provider is not likely to change his rate schedule or take on a foreign billing process in order to service such a small percentage of his medical practice.)
Our members have asked their current specialist if they will agree to join the Demonstration Project. None have stated that they would join and several have stated that they have been approached by ISOS to join and have declined. The overwhelming reasons for the professional providers declining to join the Demonstration Project is the low CMAC, the wait time for payment, (which is a minimum of 60 days, and at times is more than a year), and their perception that ISOS commits fraud, and therefore, they believe TMA is involved in or condones the fraud.
Our members have talked with the management of several of the better hospitals in Manila and have not found one that said they would join the Demonstration Project, though all of them that we have talked to have been contacted by ISOS. (One major hospital that had attempted to bill WPS directly under the current TRICARE Standard program had to stop accepting TRICARE cases for which they directly billed WPS due to the loss of more than $1,000,000. This provider also cancelled their contract with ISOS as the TRICARE Prime contractor, we have been told, due to underpayments caused by the low CMAC and slow and/or non-payment for services provided. (TRICARE Prime is restricted to Active Duty members and their families).
As of the end of September 2012, a TMA source advised us that ISOS had only recruited 30-40 providers, institutional and professional, to participate in the Demonstration Project which is to start in Metropolitan Manila, Angeles City, Olongapo City and Orion. (The Demonstration Project is scheduled to be up and running as of 1 January, 2013).
According to the 2010 Philippine census, Metropolitan Manila has a population of 11,855,975 and comprises of 638.55 square kilometers. Metropolitan Manila is made up of 16 cities and one municipality. As a comparison, Los Angeles City has a population of 3,792,621 and a land area of 1302 square kilometers based on the US 2010 census.
There are estimated 10,000-11,000 TRICARE beneficiaries in the Philippines. TMA maintains that the majority of these reside in the four designated Demonstration Project areas. If one assumes that 5,000 of these beneficiaries live in the Metropolitan Manila area, and taking into consideration the size of the Metropolitan Manila area, there is no possible way that 10 providers could provide adequate and timely care to the beneficiary population, (assuming that the other three demonstration areas each have 10 providers signed up for the Demonstration Project).
"3.2 Approved Provider List"
"A list of all approved demonstration providers maintained by the TOP contractor (see paragraph 3.1 for specific requirements for approved providers). If a specialty waiver has been granted in accordance with the process outlined in paragraph 4.9, the approved provider list must be annotated with this information so that beneficiaries understand their options when seeking care in demonstration area(s)."
*Based on the current recruitment success, the number of specialties that will be required to be waivered will be the majority of the 18 major professional specialties identified by the American Medical Association. That does not include the non-professional specialties such as mid wives, physical therapist etc., and the institutional providers that will be required to provide medical care for the TRICARE beneficiaries. These include hospitals, clinics, laboratories, x-ray labs, dialysis centers, physical therapy clinics, birthing centers etc.
Considering the size of Metropolitan Manila and the density of population, the numbers and mix of commercial and private vehicles and the requirement to ensure reasonable transit times for care, there would need to be 100 providers, or more, in order to provide medical care for the TRICARE beneficiaries in the Metropolitan Manila area. And, from the information we currently have, ISOS has only been able to recruit 30-40 providers, (and we assume that a minimum of 4 of those are hospitals; one for each Demonstration Project area). The Demonstration Project is due to start in the four designated areas on 1 January, 2013, but it was originally slated to begin in the spring of 2012 and had to have the start date pushed back due to slow progress in recruitment of providers. It doesnt make sense to go forward with the project until a reasonable mix and number of tier 1 providers have been identified and placed under contract. From what we have learned on the ground, ISOS has only been able to recruit tier 3 providers for the Demonstration Project.
"3.3 Certified (Philippines) Provider"
"A provider who meets the on-site verification and provider certification requirements outlined in Chapter 24, Section 14, but who has not agreed to the additional conditions required for approved demonstration providers. For example, a certified provider in the Philippines may require a TRICARE beneficiary to pay up-front for services and file their own claim for reimbursement."
"3.4 Non-Approved (Demonstration) Provider"
"Any provider in the Philippines who is not recognized as an approved demonstration provider and is not listed on the TOP contractors approved provider list. This includes any certified Philippine providers (as defined in Chapter 24, Section 14) in demonstration locations who are not listed on the approved provider list."
*Thus, if the provider is located in Metropolitan Manila and is of a specialty that ISOS has recruited for the Demonstration Project but has not contracted with ISOS as a Demonstration provider, no beneficiary in the Philippines may use that provider. According to the July, 2012 certified provider list, there are 1,618 TRICARE certified providers listed in the Metropolitan Manila area, (all specialties and institutional providers are included in this number). These providers are distributed over the 16 cities and one municipality that comprise the Metropolitan Manila area. There are currently 4,820 TRICARE certified providers listed on the certified provider list for all of the Philippines. 33.6% of all TRICARE certified providers are located in the Metropolitan Manila area.
That means that potentially one third of all cardiologist are located in Metropolitan Manila, but all except for 1-3 of these will be off limits to all Tricare beneficiaries in the Philippines when the Demonstration Projects begins on 1 January, 2013. Some of these cardiologists are the top cardiologist in the Philippines, but they will be off limits to all beneficiaries.
Why are there so many TRICARE certified providers listed for the Metropolitan Manila area? It is because these providers are located in the areas where TRICARE beneficiaries live and they have been vetted by the beneficiaries and found to be competent, qualified providers. Assuming that ISOS can contract with 3 each of the 18 major specialties and contracts with 3 each; hospitals, laboratories, dialysis centers, x-ray labs and physical therapy clinics, they would have only 69 contracted providers to cover an estimated 5,000 beneficiaries. There would be a major denial of access based on the new Demonstration Project because beneficiaries would be required to travel long distances, taking 1-3 hours to reach the Demonstration contracted provider.
In order to get a feel of what normal traffic is like in Manila, go to https://www.google.com/search?q=pictures+of+traffic+in+manila&hl=en&client=firefox-a&hs=54j&rls=org.mozilla:en-US:official&prmd=imvns&tbm=isch&tbo=u&source=univ&sa=X&ei=E0ByUPnqJufYigeys4GgAg&ved=0CB8QsAQ
The reason that a beneficiary uses a provider in their local area is to avoid the daily traffic jams in Manila. A short 10 kilometer trip can take one to two hours if you happen to need to be at the providers office during the times of 7-9 AM, 10 AM-1:30 PM and 4-7PM. Will TMA set the maximum travel time to reflect that of the US TRICARE Prime standards: 30 minutes? (See HA POLICY: 11-005 - Military Health System ) (see excerpt below)
"3. Routine Care: Beneficiaries must be offered an appointment to visit an appropriately trained provider within 7 calendar days and within 30 minutes travel time of the beneficiarys residence."
*In order to meet the travel time limits that TRICARE beneficiaries in the U.S. who voluntarily sign up for TRICARE Prime have as a policy criteria, ISOS would need one of each 18 specialist, along with the institutional providers, for each of the 16 cities and 1 municipality in Metropolitan Manila area. They are nowhere near that level in their recruitment and have already had more than 24 months to do the recruiting. (TMA Program Integrity presented the outline of the Demonstration Project at a 5 August 2010 power point presentation at the Communications and Customer Service Conference). Below is page 17 of that presentation.
" Establish a Demonstration Project 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"
"4.1 This demonstration is applicable to all TRICARE Standard beneficiaries who reside in the Philippines and receive care in designated demonstration area(s). The demonstration is also applicable to beneficiaries who are receiving the TRICARE Standard benefit under TOP TRICARE For Life (TFL), TRICARE Retired Reserve (TRR), TRICARE Reserve Select (TRS), or TRICARE Young Adult (TYA) (Standard option) programs, who reside in the Philippines."
*In other words, any Philippine TRICARE beneficiary who sees a provider inside of the Demonstration Project boundaries must use only the Demonstration Project contracted provider. Over one thousand five hundred TRICARE certified providers may be de-certified in Metropolitan Manila alone if all 18 major specialties are contracted under the Demonstration Project.
"4.2 For demonstration purposes, beneficiary residence will be determined by the address listed on the claim. This rule applies regardless of the residence address listed in Defense Enrollment Eligibility Reporting System (DEERS)."
*Why even worry about the beneficiaries address since any beneficiary who uses a provider within the boundaries of the Demonstration Project MUST use a Demonstration Project contracted provider? Of course this would make it impossible for a beneficiary that resides just inside the Demonstration Project boundaries to be reimbursed if he uses a provider outside of the Demonstration Project, even if that provider happens to be 500 meters from the beneficiarys house.
"4.3 Demonstration area(s) will be determined by TRICARE Management Activity (TMA) and will be publicized at least 60 calendar days in advance of the effective date for each location. TMA anticipates using a phased approach to implement the demonstration in multiple locations."
*TMA will need to provide a detailed map to show the exact boundary lines for inside or outside of the Demonstration Project area because, unlike the US under TRICARE Prime which uses zip codes for boundary determinations, boundary lines for Philippine cities, municipalities and barangays are not as easy to determine.
"4.4 TRICARE Standard beneficiaries who reside in the Philippines, in accordance with paragraph 4.2, and receive care in designated demonstration area(s) must receive all care from approved demonstration providers, unless a specific waiver has been granted (see paragraphs 4.8 and 4.9)."
*The time limits for approval/denial of waiver applications have not been disseminated to the beneficiaries; however there are numerous questions that need to be addressed immediately.
1. According to paragraph 4.8 below, Beneficiary waiver requests should be submitted in writing to the TOP contractor. The latest ISOS website page states; "Beneficiaries will be able to send waiver forms to Global 24 Network Services, International SOS subcontractor in the Philippines, by mail or fax." Will ISOS provide a web based, (secure), fill in form so that immediate waiver request may be submitted?
2. How long will ISOS have to make the waiver decision? Will the clock start when the request is received by ISOS or when postmarked?
3. How long after ISOS makes its initial waiver decision must ISOS notify the beneficiary of the decision? And how will ISOS notify the beneficiary of the decision; by Philippine mail, (expect 2-4 week delivery time)? By U.S. mail, (many beneficiaries have no access to US mail through the RAOs)? By Philippine courier, (the fastest means of notification, but will incur a higher cost for the contractor which ISOS may not want to pay)?
4. Since TAO-P is the appellate authority on denied waiver request, (and appeals cannot be made to any other authority), how long does TAO-P have to make the appeal decision? Will waiver appeals be accepted through email? TAO-P is located in Japan meaning that beneficiaries would need to use international mail to file an appeal, thus causing unwarranted delays in the appeal of a waiver denial. And then, how will TAO-P notify the beneficiary of the appeal decision? If it is through international mail, again there would be unwarranted delays involved.
5. What is the maximum amount of time from the date of the initial waiver request until the final determination must be made?
6. What provisions have been made for urgent waiver request, (a request where the consulting physician strongly recommends immediate consultation to a specialist who is considered the best to handle the medical case presented)? How will referrals by a Demonstration contracted provider to a non-Demonstration contracted provider be handled? Will there be an automatic waiver for these situations? None of these questions are addressed in the Tricare Manual, but these questions need to be seriously looked at and planned for.
"If these beneficiaries receive care from a non-approved demonstration provider without a waiver, TRICARE will not cost-share the claim and the beneficiary will be responsible for 100% of the charges. Normal TRICARE cost-shares and deductibles apply to care rendered to eligible beneficiaries by approved providers under the terms of the demonstration. Additionally, when a beneficiary receives care from an approved provider in a designated demonstration area, the provider will file the claim on the beneficiarys behalf, and the provider will collect only applicable cost shares and deductibles after receipt of the TOP EOB. The beneficiary will be held harmless for denied charges rendered by an approved demonstration provider unless the beneficiary was notified in writing that the care provided was not a covered benefit prior to receiving the care. Beneficiary-submitted claims for services provided by an approved demonstration provider in an approved demonstration area shall be denied unless it is submitted with proof of payment showing that the beneficiary has paid for the service(s)."
*The statement; Beneficiary-submitted claims for services provided by an approved demonstration provider in an approved demonstration area shall be denied unless it is submitted with proof of payment showing that the beneficiary has paid for the service(s), is actually a hedge for TMA and ISOS. The Demonstration Project contract with the provider requires the provider to provide the medical care without any upfront payment and to then file the claim with WPS for payment. Only after WPS has processed the claim and sent the provider his payment and the EOB, (Explanation of Benefit), may the provider bill the beneficiary for the deductible, (if applicable), and the co-pay.
What this language does is give TMA/ISOS an out once the Demonstration contracted providers refuse to file claims, (in violation of the Demonstration Project contract), because of the slowness of payments, underpayments or outright denial of payments on claims. At this point, the beneficiary is in the same position that they were in prior to the implementation of the Demonstration Project, (the requirement to pay for medical care up front and then file a claim), but now he also has his choice of providers eliminated. As for the requirement that this type of claim must have a receipt showing that he has paid the provider for the services, that is also a bogus statement since it is already a mandatory requirement for all claims from the Philippines to include a Philippine Government mandated official receipt with the claim, otherwise WPS will not process the claim.
"4.5 Active Duty Service Members (ADSMs) are not eligible for TRICARE Standard and therefore are not included in this demonstration, regardless of their residence address or enrollment status. ADSMs not enrolled in TOP who are on Temporary Additional Duty/Temporary Duty (TAD/TDY ), deployed, deployed on liberty, or in an authorized leave status in the Philippines shall follow referral/authorization guidelines for TOP Prime Remote enrollees (see Chapter 24, Section 26)."
"4.6 This demonstration is not applicable to beneficiaries enrolled in TOP Prime, TOP Prime Remote, TRICARE Prime, TRICARE Prime Remote (TPR), TRICARE Prime Remote for Active Duty Family Members (TPRADFMs), or TYA (Prime option). Additionally, this demonstration is not applicable to TRICARE Standard beneficiaries whose home address (as determined by the claim) indicates a residence other than the Philippines. The demonstration is also not applicable to TRICARE Standard beneficiaries who reside in the Philippines (as determined by the claim) when they receive care from a provider who renders care in a location that is not included in the demonstration."
"4.7 All TOP requirements regarding utilization management, case management, quality management, and preauthorizations are applicable to demonstration participants. The TOP contractor is not required to enroll participants into the demonstration or to provide referral/ authorization services to demonstration participants unless the requested service requires preauthorization (per Chapter 7, Section 2 and TPM, Chapter 1, Section 7.1). The TOP contractor shall conduct a covered benefit review upon beneficiary or provider request; however, an authorization letter will not be generated except for those services which require preauthorization."
*The statement; The TOP contractor shall conduct a covered benefit review upon beneficiary or provider request; however, an authorization letter will not be generated except for those services which require preauthorization is extremely frustrating. If a beneficiary or provider wishes to ensure that the medical procedure is a covered benefit they can ask ISOS, but ISOS is not required to, (which means they will never), put the decision in writing. Thus, if the ISOS representative tells the beneficiary or provider that the procedure is a covered benefit and WPS later denies the claim, the beneficiary or provider has no recourse. I dare anyone to try to get ISOS to admit that they gave bad advice that was relied upon, and even if they did, they would never take responsibility for paying the disallowed amount.
Our experiences to date with getting accurate responses from ISOS personnel, has been very disappointing. When asked if there is a certified provider in a specific area, the ISOS personnel have not even been able to read their own certified provider list. Some ISOS employees did not even know that there was a list. One ISOS employee told a beneficiary that he should go to a web site that listed Philippine physicians and that he could pick anyone he wanted to use, (even though the special rules for the Philippines requires that a beneficiary only use Philippine certified providers).
"4.8 TRICARE Standard beneficiaries who reside in the Philippines may request a waiver if they elect to receive care from non-approved providers or facilities in a demonstration area. Beneficiary waiver requests should be submitted in writing to the TOP contractor and will be considered on a case-by-case basis. Except for emergency care (which never requires prior approval), beneficiaries are encouraged to submit waiver requests prior to receiving care. However, the TOP contractor will also consider waiver requests that are submitted after care has been rendered. The Director, TRICARE Area Office (TAO)-Pacific will make the final determination if the beneficiary disagrees with the TOP contractors decision. In such cases, the TOP contractor shall forward all supporting documentation and rationale regarding the waiver denial determination to the Director, TAO- Pacific to assist in the final determination. Some examples of potential beneficiary waiver situations include (this list is not all-inclusive):
Beneficiaries who were engaged in an ongoing episode of care with a non-approved provider when the demonstration began, and who wish to continue care with their established provider.
Beneficiaries who are unable to obtain an appointment with an approved provider within the appropriate time frame (based on TRICARE access standards for urgent, routine, and specialty care).\"
*The TRICARE manual does not state what the appropriate time frames are for urgent, routine and specialty care. The beneficiary is left to guess or to spend time on the internet researching these limits. The manual does not state what proof of failure to obtain an appointment within the appropriate time frames are. Obviously this information is important to know so that the beneficiary may include the appropriate documentation with the claim in order to avoid a denial of 100% of the claim for failure to use a demonstration contracted provider.
"Note: Waivers for emergency care rendered by non-approved providers or facilities shall be approved on a retrospective basis based on TRICARE policy. Emergency care never requires preauthorization."
*Our experiences show that this is not being handled the way it is written. The current WPS practice is that if a claim is received by WPS from a beneficiary for emergency care provided by a non-certified provider, (hospital, attending physician etc.), ISOS is requested to certify the provider. If the provider refuses certification or was previously denied certification in the past, (no matter what the reason for denial was), the claim is denied and the beneficiary is refused reimbursement. This is the case, (and we have several examples), even when the beneficiary was brought to the hospital in a coma. In the US the only question that is asked in emergency care cases when the provider is not certified is: was this truly an emergency?
"4.9 Since provider participation in this demonstration is voluntary, there may be situations where the TOP contractor is unable to recruit a sufficient number and mix of approved providers in all specialties in designated demonstration areas. In these situations, the TOP contractor may request a specialty waiver so that beneficiaries can receive care from non-approved (certified) providers in accordance with normal TRICARE Standard reimbursement policy. The TOP contractor is responsible for identifying any anticipated or actual gaps in coverage by approved providers in demonstration area(s), and submitting a specialty waiver request in writing to the Director, TAO- Pacific. The waiver request shall include a description of the contractors efforts to recruit approved providers in that particular specialty, as well as any perceived or known barriers to participation in the demonstration. If the Government approves the specialty waiver, the contractor shall implement processes to ensure that claims for that specialty (in the designated demonstration area) are processed under normal TRICARE Standard rules. This specialty waiver process will ensure that TRICARE Standard beneficiaries will not be liable for 100% of the charges (as described in paragraph 4.4) if the TOP contractor is unable to recruit approved providers in a particular specialty."
*We anticipate this policy to cause numerous issues, denied claims and protracted appeals. We can envision a beneficiary seeing a specialist that is waivered because the beneficiary believes his medical issue falls into the area of that specialty, but upon receipt of the claim by WPS, we can see WPS deciding that this specialty was not appropriate for the medical condition presented.
Unfortunately TMA and WPS refuse to understand that the custom of medical practice in the Philippines is diametrically opposed to the customs in the US. In the US the patient sees a General Practitioner, (GP), who will refer or recommend the patient see a specialist for the medical condition presented. In the Philippines, there are few GPs. The patient will seek out a specialist in the area that they believe they need. The specialist may, after making the initial examination and possibly ordering laboratory test, refer the patient to a specialist that handles the specific medical problem the first specialist identified.
Thus, the waiver system is a potential major problem for Philippine TRICARE beneficiaries. However, TMA ignored our recommendation to make the Demonstration Project a voluntary program, which means that the beneficiary could decide to use the Demonstration contracted providers in order to avoid the upfront cost, but would still have the flexibility to choose any certified provider they wish, whether it is because the provider is closer to their residence or because the provider is one that they trust and know.
Eventually, once ISOS had contracted with a large enough mix of quality providers and in enough locations, the beneficiaries would migrate to the Demonstration Project contracted providers in order to avoid the upfront cost for medical care.
"4.10 A provider may be removed from the list for administrative reasons or may be removed for cause by the TOP contractor. The Government may also direct the TOP contractor to remove providers from the list for cause. A provider removed from the approved list may submit a written request to the TOP contractor for reconsideration. If the TOP contractor upholds the removal, the provider shall be given the right to appeal to the Director, TAO-Pacific. If the appeal decision is upheld by the Director, TAO-Pacific, there is no right to further appeal."
"Note: The appeal process does not apply to certified providers who are not selected by the TOP contractor to participate in the demonstration as approved providers. Recruiting and retaining a sufficient number and mix of approved providers in demonstration area(s) is the responsibility of the TOP contractor. The TOP contractor is not required to offer approved provider status to every current certified provider in demonstration area(s)."
"4.11 Claims for a provider removed from the list will be processed in accordance with Chapter 13, Section 6, paragraph 4.4. The list will be updated on the contractors web site on the first of the month following the provider being removed from the list."
"5.0 TMA AND TOP CONTRACTOR RESPONSIBILITIES"
"5.1 The TMA Deputy Director (or his or her designee) shall:"
"5.1.1 Determine the geographical area(s) for the demonstration and the phased implementation approach and timeline (if applicable) and communicate this information in writing to the TOP contractor no later than 240 calendar days prior to the start of health care delivery under the demonstration."
"5.1.2 Establish a process to allow a provider to appeal his/her removal from the approved list (see paragraph 4.10)."
"5.1.3 Issue final determinations regarding waiver requests from beneficiaries who elect to receive care from non-approved demonstration providers (see paragraph 4.8)."
"5.1.4 Conduct periodic review and evaluation of the demonstration."
"5.2 The TOP contractor shall:"
"5.2.1 Submit an implementation plan 180 days before the start of health care delivery under the demonstration in accordance with the requirements identified in the Contract Data Requirements List (CDRL), DD Form 1423-1, SP050 (Philippines Demonstration Implementation Plan). The contractor shall revise the plan if additional demonstration area(s) are identified by the Government after the contractor submits the implementation plan."
"5.2.2 Submit monthly data reports in accordance with the requirements identified on the CDRL, DD Form 1423-1, M360, Philippines Demonstration Data Report."
"5.2.3 Recruit and retain a sufficient number and mix of approved providers in demonstration area(s) to ensure access to the full range of covered TRICARE benefits, unless a specialty waiver has been requested. Approved providers must agree to comply with the demonstration participation requirements in paragraph 3.1."
"5.2.4 Establish and maintain a list of all approved demonstration providers, including each providers specialty, subspecialty, gender, work address, work fax number, and work telephone number for each demonstration location, and whether or not they are accepting new TRICARE patients. The approved list of providers must be submitted to TMA no later than 120 calendar days prior to the start of health care delivery under the demonstration. The TOP contractor shall provide beneficiaries with easy access to both the approved provider listing and the certified provider listing via a user-friendly searchable World Wide Web (WWW ) site and any other means established at the contractors discretion no later than 60 calendar days prior to the start of health care delivery in each demonstration area. Information on the WWW site and any other electronic lists shall be current within the last 30 calendar days. At a minimum, the data base shall be searchable by provider location, provider name, and provider specialty (if available)."
"5.2.5 Provide certification oversight and monitor quality of care for providers and institutional facilities as prescribed in Chapter 24, Section 4; 32 CFR 199.6; and TPM, Chapter 12."
"5.2.6 Establish a waiver process for beneficiaries who reside in the Philippines and who request or receive care from non-approved providers or facilities in a demonstration area (see paragraph 4.8)."
"5.2.7 Develop and publish materials to educate beneficiaries and providers on all aspects of the Philippines Demonstration Project. In addition to providing specific information regarding the demonstration, the TOP contractor shall educate approved providers on aspects of the TRICARE program, including (but not limited to) TRICARE eligibility requirements, TRICARE benefits, claims submission requirements, and the requirements in 32 CFR 199.9 and Chapters 13 and 24 as they relate to anti-fraud activities."
"5.3 TMA and the TOP contractor shall:"
"5.3.1 Develop and implement a communication plan to ensure that beneficiaries and providers are informed regarding the area(s) that are participating and not participating in this demonstration. The communication plan shall also include the process(es) for educating beneficiaries and providers regarding the demonstration rules and business processes, to include the processes for requesting waivers."
*I have lived in the Philippines for 11 years and have only received 3, (THREE), educational letters from TMA/ISOS. One from TAO-P in 2006 or 2007 advising beneficiaries not to sign blank claim forms for a provider. One in 2010 advising that ISOS will be the new TOP contractor and one from ISOS advising that they are the new TOP contractor.
In numerous letters to Maj Gen Granger, (the former Deputy Director of TMA), in 2007 and 2008 I have repeatedly pressed the need for beneficiary education materials to be sent to Philippine beneficiaries. A TMA employee at the Communications and Customer Service division, (about 18 months ago), acknowledged that the beneficiary education for the Philippines was non-existent and promised to send the issue up the chain of command to resolve the discrepancy. There has been no positive action taken by TMA to date on this issue. With the above information, why should we believe that TMA and ISOS will provide us with current, accurate and timely beneficiary education materials? Everything we know about the Tricare in the Philippines program we have learned through inside sources and slips of the tongue by ISOS, WPS and TMA personnel.
We have been told that ISOS will conduct small meetings with the RAO leadership, (Retiree Activity Office), and some of the leadership of some of the Military Service Organizations, (MSO), in the Philippines at the end of October but have emphatically ruled out town hall meetings with beneficiaries that some TMA officials had recommended because they were afraid that the meetings could get loud and raucous. That alone reflects that TMA and ISOS know that they are screwing the beneficiaries in the Philippines.
TMA and ISOS expect the RAOs and MSOs to be able to explain, in detail, the Demonstration Project to all of the 11,000 beneficiaries in the Philippines, which is an unreasonable expectation since many elderly beneficiaries are not members of the RAOs or the MSOs and many beneficiaries are survivors whose parent or guardian are not affiliated with the RAOs or MSOs. It is highly unlikely that ALL beneficiaries will be informed of the Demonstration Project, and when those that did not get the word about the rules and regulations of the Demonstration Project file a claim with WPS in violation of the RULES they will find that the claim is denied because they did not follow the Demonstration Project rules. There is nothing in the Tricare Manual concerning waivers or grace periods for beneficiaries that fall into this category.
"5.3.2 Establish timelines and processes to facilitate prompt processing of waiver requests and provider appeals in accordance with demonstration policy (see paragraphs 4.8, 4.9, and 4.10)."
"6.0 CLAIMS PROCESSING AND REIMBURSEMENTS"
"6.1 All TRICARE Encounter Data (TED) records for this Demonstration must include Special Processing Code PH (Philippines Demonstration Project)."
"6.2 TRICARE Standard beneficiaries residing in the Philippines who receive care from approved providers in demonstration area(s) will only be liable for normal cost-shares and deductibles applicable under the TRICARE Standard option. TRICARE Standard beneficiaries residing in the Philippines who receive care from non-approved providers in demonstration area(s) will be liable for 100% of the cost unless a beneficiary waiver or a specialty waiver has been granted (see paragraphs 4.8 and 4.9)."
"TMA will evaluate the demonstration using a combination of administrative and survey measures to determine whether access to care is adequate under the terms of the demonstration. In addition, a cost analysis will be conducted to determine the cost impact to beneficiaries and the Government. Finally, the demonstration will be evaluated to determine the impact (if any) on the occurrence of aberrant claims activity."
*Why didnt TMA send out surveys to Tricare beneficiaries in the Philippines prior to the final determination to conduct the Demonstration Project? We believe it is because they do not want our inputs.
"8.0 EFFECTIVE DATE
The Philippines Demonstration Project is anticipated to last for three years. The effective date is January 1, 2013. - END -" C-74, March 21, 2012
*Finally, TMA sent out a Press Release the other day discussing the great Demonstration Project, (http://www.tricare.mil/mediacenter/press_article.aspx?fid=616), which states; " Starting Jan. 1, 2013 TRICARE is launching a Demonstration Project in designated areas of the Philippines to provide beneficiaries access to high-quality health care from approved demonstration providers. TRICARE Standard beneficiaries who live in the Philippines and receive care in the designated demonstration areas may participate."
*The Tricare Manual makes it clear that beneficiaries MUST participate. This is mandatory, not voluntary. The press release goes on to state;
"Beneficiaries who live in the Philippines and want to participate in the demonstration must provide their physical address to the approved provider to submit claims on their behalf. Post office boxes and retirement activity office boxes are not acceptable."
*Again, the Tricare Manual language makes it clear that ALL BENEFICIARIES IN THE PHILIPPINES MUST PARTICIPATE when they use a provider within the boundaries of the Demonstration Project or if their physical residence is within the boundaries of the Demonstration Project. There is nothing voluntary about that language. (See http://tricareoverseasphilippines.wordpress.com/2012/10/11/tricare-spin-doctors-are-at-it-again-do-we-have-a-deal-for-you/#more-138 for more on this press release).
That’s a lot of facts you put together. I have noticed the same thing here in Grand Rapids. I have taken to calling it Obamacare to the liberals I know. They all think the program is lousy and I keep telling them their turn is coming.
Government is too big already, this expansion of government , this takeover of healthcare is tyranny.
Government is the problem and it has grown at all levels every single year, every month for the last 100 years.
They is tracking our kids in schools with smart IDs, Moochel is telling kids what they can eat, Bloomberg banned big sodas in New York, Obama took over our healthcare, They banned 100 watt light-bulbs , they tell us that we have to discriminate to hire people (affirmative action), soon cars will have to be 27 mpg , etc. This crap has to stop.
I started to write a first draft on how to finally limit government for the first time ever. something has to be done as the problem is government. It's in personal page here.
Government is too big already, this expansion of government , this takeover of healthcare is tyranny.
Government is the problem and it has grown at all levels every single year, every month for the last 100 years.
They are tracking our kids in schools with smart IDs, Moochel is telling kids what they can eat, Bloomberg banned big sodas in New York, Obama took over our healthcare, They banned 100 watt light-bulbs , they tell us that we have to discriminate to hire people (affirmative action), soon cars will have to be 27 mpg , etc. This crap has to stop.
I started to write a first draft on how to finally limit government for the first time ever. something has to be done as the problem is government. It's in personal page here.
I did not read your post...just too long.
I was never in the military, so I guess it does not apply to me anyway. It must be some vet thing.
That being said, I have PhilHealth which does not pay so much, but it is very cheap and it will get you into a hospital.
It did pay a fair amount on the birth of my son, 18 months ago....I am satisfied with it.
I have no intentions of ever returning to the USSA.
Haven’t you heard? We all belong to the government now.
Obamacare-Killing old white seniors starting in 2014!
Thank you for the post, this is a very important topic to me, and I suspect there are many active duty and retired military here on FR, as well as Vets who use VA healthcare will be greatly impacted by obamacare.
I’ve heard there are many changes coming to Tricare due to the implementation of obamacare...none of the changes are good, basically we will be paying much, much, more for a great deal less.
I still take Tricare patients, probably out of some financially suicidal moral/patriotic weakness. It’s probably not going to be an option much longer.
The simple truth for patients is this: if you let someone else pay for your healthcare, they will want to control it. And a reading of Ms. Sebelius’ writings will also make it clear that they mean to control every other aspect of your life, and “The Environment” as well - all “for the sake of your health”.
Service members, vets and others caring for the defense of our country and the welfare of our troops need to put pressure on Congress to exempt TRIUCARE from the Affordable Health Care Act
My opinion is that DOD wants to move all retirees, (and maybe Active Duty Family Members), out of Tricare and into an ObamaCare insurance program. This would mean that DOD transfers billions of dollars to ObamaCare, making the ObamaCare cost lower to the US Treasury. It’s the same as taking $716 Billion from Medicare and putting it into ObamaCare.
You are correct. As I say, the only way to prevent it is to get the Congress critters to commit in this election cycle to exempt TRICARE and all current and future beneficiaries from Obamacare. It needs to be an issue in every congressional district in the nation. I’d like to see the issue come up in the next debate
Obamacare is solent green plain and simple. General Patton, Mcarthur where are you? the enemy is beyond the gate
Yea. What is so frustrating is the Geniuses at Tricare come up with this idea without having ever spent any time on the ground learning how the Philippine medical system works. Then they award the contract to set up the program and write the rules to the contractor that has the contract to certify hospitals and doctors to be allowed to treat Tricare patients.
So, on 30 October I go to a briefing on the Demonstration Project that is scheduled to start 1 January. For the Metropolitan Manila area they contracted with exactly ONE hospital which is located in the busiest, most traffic congested section of Manila and tell us that we must travel 2-3 hours to see the doctors that are located at that hospital, but that if we don’t use THEIR doctors, Tricare won’t reimburse us. The problem is, it will cost more to travel to see THEIR doctor than it would for us to pay a doctor with an office within 30 minutes of our homes.
We took a video of the filth in the one hospital that they got to agree to be their hospital in one of the other demonstration project areas. Check out this YouTube http://youtu.be/BOQAVfgf7yQ and also check out my latest article on this at http://www.freerepublic.com/focus/vetscor/2956757/posts?page=7
When we asked about the waivers they say that we can file in order to maintain our doctor that has been treated us for serious conditions, they did not want to tell us how long the have to make the waiver decision. we finally got them to tell us they have 5 working days and if they deny the waiver we can appeal to Tricare. When we asked how long Tricare had to make the appeal decision, they said “we don’t know, we’ll have to ask Tricare and get back to you”
Less than 60 days until the start date and they don’t even know what the rules of the program are that they are going to require we follow. Nothing of the details of how the program is supposed to work is in writing. They are just going to make it up as the go along.
“”4.9 Since provider participation in this demonstration is voluntary, there may be situations where the TOP contractor is unable to recruit a sufficient number and mix of approved providers in all specialties in designated demonstration areas. “
I wonder why providers will not be flocking to join this? Could it be low reimbursement and the threat of fines and prison from rapacious regulators?
Maybe they will make participation mandatory for physicians. I’m sure that doctors will perform well with a gun to their heads.
Tricare can’t force any providers to participate in providing medical care to any Tricare beneficiary. And this is especially true overseas. The Demonstration Project has been in place for two months now, (it had to be delayed because they couldn’t get providers to join), and it has been a very rocky start.
What was supposed to be a program with providers of most of the required specialties represented in the program has, to date, 42 specialties that are waived, (meaning that beneficiaries must use non-Demo project providers for those specialties and pay up front, just as they did before the Demo project). In the three Demo areas, the highest number of specialties represented is 22. But there are many specialties not represented that are needed.
Another issue that has come to light is that the Approved providers are being told that they can charge up to the Champus Maximum Allowed Amount,(CMAC), even though their normal and customary fees are at least half of the CMAC. Thus, what was a normal $12 out-patient office visit now can be charges at $26. Of that the beneficiary must pay a co-pay of 25%, ($6.50), or more than half of what would have been the normal and customary fees. (Under the old system, the beneficiary would pay the full bill, file a claim and be reimbursed 75%,($9.00), making his co-pay $3.00. Now Tricare is responsible to pay $19.50 for an office visit that used to cost them $9.00).
Tricare’s contractor, International SOS,(ISOS), apparently has told the providers that they can charge the higher fees in order to compensate for the administrative cost of filing Tricare claims and taking the risk of no payment or underpayment of the claim. However, the charging of administrative fees is specifically prohibited by Federal Regulations. Providers are not allowed to bill Tricare for administrative fees or to hide these fees in their billing. In fact, this was one of the charges filed against Thomas Lutz, CEO of Health Visions, in the $100 million fraud case prosecuted several years ago.
The Federal Register Notice of Philippine Demonstration published 09/28/2011 http://db.tt/hhxm8Jk2 stated; “To be included on the approved list, a provider must agree to accept reimbursement at the lower of the usual and customary charges and the established fee schedule”. This new policy is a total reversal of the notice in the Federal register and is a violation of 32 CFR, 199.9;
199.9 (b) (2) Improper billing practices.
Examples include, charging CHAMPUS beneficiaries rates for services and supplies that are in excess of those charges routinely charged by the provider to the general public, commercial health insurance carriers, or other federal health benefit entitlement programs for the same or similar services.
Since Tricare, (and ISOS), know what the normal and customary charges are for the general public and have advised, (apparently, according to statements made by providers to beneficiaries), the providers to charge a higher fee in order to recoup administrative cost and the risk of non or underpayment, Tricare and ISOS are facilitating fraud upon the US Government.
I imagine that Tricare will claim that they have the authority to advise providers to double, (or more), their fees in order to entice them to be a participant in the Demonstration Project, but I doubt that they have that authority under Federal Statute or Regulations since that policy means an increase of cost to the US taxpayer and higher out of pocket cost to the beneficiaries.
Active Duty/Retiree Ping.
How many more troopers will allow themselves to be tools for this admin?