Review and Analysis of the Philippine Certified Provider Listing 12 March 2009 Since my last foray into the

complete Philippine provider list obtainable on the TMA Contract web site I spent some time working with the available data that supposedly repre sents the institutional and non-institutional provider lists on the TMA TAO-P web site. To obtain an actual list requires some experimentation but one can obtain both a n institutional and a non-institutional list, however, there are no instructions on the page tha t explains the process. Once I obtained the lists, I extracted them to separate spreadsheets wh ere I evaluated the results. These databases are some of the worst, form a data quality point of view, which I have ever seen. Providers are listed more than once since they have to be certified at mul tiple locations, a problem in itself, but in some cases, the provider s name is not spelled the sam e. Even things like changing MD to M.D. will make the provider name appear different to a computer since it is, inappropriately, all part of the name. Cities are misspelled. Provi ders are sometimes listed by city while most of the time by province and in some instance s by region, in the City field. Addresses are listed differently from one list to another and i n many instances include a city. In general, the differences amount to an additional sp ace, letter or character but that is enough to cause the computer to see them as different addr esses, hence different providers. There appears to be no rational to how the institutional an d noninstitutional categories are applied and the same applies to specialty. Hospital s, pharmacies, physicians, laboratories, dental, radiology and medical supply can be found mixe d on either listing. Many doctors and some pharmacies are listed as hospitals under one of t he specialty codes for hospitals. Code 70 -Home Health Care Agency/Physician Groups is used f or single doctors and many third party billing agencies which then allow them to file clai ms in their name for doctors that do not work for them, a major cause of fraud. I set the lists up with auto filters, which makes it easier to filter for any se lected item in any field. Doing this resulted in the following observations. First there appears to be no rational as to when something is classified as Inst itutional or Noninstitutional. As mentioned above every category of provider can be found in eit her list. It appears ISOS randomly assigns the classification to each provider without regard to function.

While there is no definition of Institutional and Non-Institutional provided wit h the TMA list I found the following definitions of Institution as it pertains to medicine. mental hospital: a hospital for mentally incompetent or unbalanced person. A nursing home, personal care facility, state school, or state hospital.

Residential facilities where groups of people live, such as nursing homes, corre ctional facilities, or homeless shelters, as well as out-patient facilities, such as dru g treatment centers or health department clinics. facilities where groups of people live, such as nursing homes, correctional facilities, or homeless shelters, as well as out-patient facilities, such as dru g treatment centers or health department clinics. While none of these provides a definitive explanation that would explain the div ision of Philippine providers into one of the two groups, common sense tells me the follo wing lists are pretty much within the intended division. However, no matter how you distribute them the distribution must be consistent, unlike the random assignment now. Institutional Non-Institutional Hospitals Physicians Laboratory facilities Physician clinics Radiology facilities Dentist Ultrasound facilities Dental Clinic Pharmacies Nurses and other licensed support personnel Medical Supply stores Optometrists My examination of these lists showed that hospitals show up on both lists as do pharmacies and just about any other type of provider. So, apparently, the designation has l ittle meaning. Another designation, Specialty, does have a significant meaning but is also not consistently applied. To demonstrate this I linked the information from the two downloaded pr ovider lists from the TMA TAO-P web sit with the same provider information from the Complete Philippine list obtained from the TMA Contract web site. The combined listings h ave a number of blanks where the provider was apparently certified in 2008 or 2009 or where poor data does not allow proper linking. However, the ones that do show up tell an in teresting, if troubling, story. The Institutional list, dated 2 Mar 2009, I extracted from the TMA TAO-P web sit e contains 1,313 providers. Based on the above list of institutions, 358 are included in er ror. Most of them are physician clinics. (For this study, I did not consider dental) This amo unts to a 27% error rate. The Non-Institutional list, dated 2 Mar 2009, I extracted from the TMA TAO-P web site contains 3,587 providers. Again, based on the above list 148 are included in err or. Most of them are Pharmacies and appear to be Pharmacies recently certified, i.e. in 2008 /2009. This

amounts to a 4% error rate. An interesting thing about the errors on the Institutional list is many of them are physician clinics but their specialty is listed as one of the Hospital designations. It s hard to imagine that anyone would accidentally think a physician s clinic is a hospital. I didn t fi nd one instance where a hospital was listed as a physician so the mistakes are differen tly one sided. Also, if these were random errors one would expect to see roughly the same perce ntage of errors in both lists. However, the number of errors in the Institutional list, w here physicians are listed as a hospital, is 27% where the errors in the Non-institutional list are only 4%. A

look at the list from the TMA Contract web site shows that more than 500 physici ans and clinics are certified as hospitals. clinics are certified as hospitals. This is important because when a physician is listed as a hospital it tells WPS that they can submit bills in their name for any kind of medical care including hospital charg es, radiology and laboratory, and many of them do and bill at rates far in excess of local rat es. Because there are so many of them in this category but so few in others, it appears ther e was some collusion between ISOS and these providers, in at least in some of the cases, to allow them to bill as a hospital. I say this because of the large differences in the error rat es and because I am personally aware of this happing, where I currently live. I reported it at the t ime and was told the individual involved was fired. If there wasn t collusion then there is an incr edible amount of errors in assigning specialty and apparently the ISOS employees have little u nderstanding of what constitutes a hospital. Because I don t have current specialty data for 20 08/2009 I cannot say if it is still going on or not, but regardless, the current provider list allows hundreds of physicians to act and bill like a hospital which leaves TMA open to fraud. A recent example was a single physician office near St Luke s Medical Center that accepted retirees and said that they would process claims for TRICARE. The end result is they file d claims in their name, as a hospital, for multiple physician visits, ambulatory surgery, em ergency room care and emergency transport, most of which was never provided and at the highes t allowable rates. Bottom-line they were paid more than $10,000 for a procedure that cost ab out $1,200. This isn t to say that all these hundreds of physicians improperly listed as a hos pital will do this but it does open the door. Another troubling finding is that 360 providers, mostly physicians are listed as Code 70 Home Health Care Agency/Physician Groups. This classification allows the provider to bill for multiple providers under their name and receive reimbursement in their name. There are very few physician groups as we know them in the Philippines. The true number ca n probably be counted on two hands. The same goes for home health care agencies. I know of one HMO that just started home health and advertise they are the first in the Philippine s. So there are few of these as well. A physician group, as we know it, is a group of physicians that come together in one location to offer various medical services at that location; som e large groups may offer satellite offices as well. These groups economize by utilizing a commo

n staff of nurses, receptionists, billers etc. Since local providers seldom employ nurses and none employ billers there is litt le need to consolidate to economize. In some areas, someone will build a medical practice b uilding where individual practitioners will rent a small clinic; these are usually in pr oximity to hospitals. In some instances, two providers, usually a man and wife, will combin e their practice into one clinic and use a single receptionist who also collects cash fe es after the visits. But that is the extent of consolidation. There is a group; I call Third Party Billers that utilize the shortcomings in the TMA systems to maximize their profit at the expense of TRICARE. These groups are certified a s a physician group by ISOS and it seems to me they should know these are not true g roups. Some are based around an actual physician s clinic while others are nothing more t han a group of administrative personal and a few nurses with not one full time physici an. They

utilize the TMA policy that requires certification of a provider at any location where they may see patients to have various providers certified at their address. They utilize the physician group designation to bill, in their name, for these group physicians, laboratory, radiology etc. In reality, what happens is the patient contacts the group who makes an app ointment for them at a local provider. A group employee meets the patient at the provider s offic e and insures the provider completes and signs a short note showing the patient was se en on their letterhead; they tell the physician they need it for the patient s record. Then th ey pay cash for the visit, usually around six to ten dollars. If the provider is not certified, they contact ISOS and request that a new group physician be certified. They explain to the physician that they are a U.S. servicemen s medical group and need certain documents from him so he ca n see them. When ISOS shows up at the groups office the group provides all the necessary documents and signatures; ISOS never sees the doctor as they never see patients at the group location. Once the provider is certified or if they are already certified th e group files a claim at or near the maximum allowable charge. Many, but not all, also r equire the patient to pay their deductibles and co-pays. They agree to this because, even t hough it costs them more, they know they don t have to worry about paying for an expensive inpati ent stay up front or face the possibility of being refused admission. In addition they kn ow they don t have to worry about finding a certified provider on a list that doesn t show speci alty or see a provider that is not certified only to find that WPS denies the claim because th e provider is not certified which leaves the average retiree without any recourse but to eat t he bill. see patients to have various providers certified at their address. They utilize the physician group designation to bill, in their name, for these group physicians, laboratory, radiology etc. In reality, what happens is the patient contacts the group who makes an app ointment for them at a local provider. A group employee meets the patient at the provider s offic e and insures the provider completes and signs a short note showing the patient was se en on their letterhead; they tell the physician they need it for the patient s record. Then th ey pay cash for the visit, usually around six to ten dollars. If the provider is not certified, they contact ISOS and request that a new group physician be certified. They explain to the physician that they are a U.S. servicemen s medical group and need certain documents from him so he ca n see them. When ISOS shows up at the groups office the group provides all the necessary documents and signatures; ISOS never sees the doctor as they never see patients

at the group location. Once the provider is certified or if they are already certified th e group files a claim at or near the maximum allowable charge. Many, but not all, also r equire the patient to pay their deductibles and co-pays. They agree to this because, even t hough it costs them more, they know they don t have to worry about paying for an expensive inpati ent stay up front or face the possibility of being refused admission. In addition they kn ow they don t have to worry about finding a certified provider on a list that doesn t show speci alty or see a provider that is not certified only to find that WPS denies the claim because th e provider is not certified which leaves the average retiree without any recourse but to eat t he bill. Attached you will find three spreadsheets. QryInstitutionalList.xls, QryNonInstitutionalList.xls and MasterListExamples.xls. The first two lists are an extract of the 2 Mar 09 lists on the TMA TAO-P web page showing providers that appear to be improperly listed based in the Institutional and Non-institutional category. Add itionally the lists were linked with the old, but complete, 2000 2007 Philippine provider list to show, where available the specialty. This is where you will find many physicians liste d as hospitals. The data was so bad and inconsistent that it took me six hours of work to partia lly clean up the data for this presentation. The third spreadsheet, extracted from the 2000-2 007 Certified Provider listing from the TMA Contract web page includes three sheets. One shows the bad state of the Specialty codes, another lists all providers with a Code 70 -Home Hea lth Care Agency/Physician Groups specialty and the last, non-hospitals that have a specia lty listing as a hospital. The extracted list of non-hospitals that are listed with a specialty of Hospital on the TMA Contract provider list show more than 500. As mentioned above these doctors are authorized by this designation to file claims as a hospital. The last sheet show s providers and clinics designated as Code 70 -Home Health Care Agency/Physician Groups, of whic h there are 360. Recommendations: Investigate the practices at ISOS to discover how they determine the Institution al and Noninstitutional groupings. If TAO-P agrees with the groupings or provides a differ ent grouping, require ISOS to clean up the current database to properly reflect these grouping s. Investigate the practices at ISOS to discover how they determine the Specialty o f providers

and specifically how they determine that a provider is a hospital or physician g roup. Correct

any shortcomings or collusion to eliminate the improper classification of non-ho spitals as hospitals and providers as physician groups and require that ISOS clean up the c urrent database. llusion to eliminate the improper classification of non-hospitals as hospitals and providers as physician groups and require that ISOS clean up the c urrent database. The current database is poorly implemented which allows for multiple mistakes in spelling, provider classification, specialty, addresses etc. The consequences of bad data from this database are over paying for care in the Philippines and the inability of benefi ciaries to locate certified providers in their location. ISOS should be instructed to develop a da tabase that requires multiple edits on data entry. Last names and first names should be in s eparate fields. There should be a viable specialty field for use by beneficiaries so they can lo cate providers in their area. ISOS should be required to determine and record in the database the appropriate specialty of physicians, i.e. Surgeon, Urologist, Pediatrician, OB/GYN, etc. Inc lude this field on all future Certified Provider lists published on the TMA TAO-P web page. If a separate field is needed for payment rules, add it. The current City field should be rename d Province and the province of all providers listed in this field. An additional fie ld City should be added to list the actual city where the provider practices and the cit y should be removed from being part of the Address field. Implement other changes as necessary . ISOS should be required to recertify all providers listed with a code that desig nates a specialty of Hospital and adjust the specialty as necessary. ISOS should be required to recertify all providers listed with Code 70 -Home Hea lth Care Agency/Physician Groups using a strict definition of what constitutes a Physicia n group and remove the designation from those that do not meet the criteria. TMA should remove the requirement to certify providers at all locations where th ey may or might treat patients and instead certify them using their primary clinic address . This will help eliminate providers being used by Third Party Billers , as defined above since any checks from WPS will go to the provider and not the group. Ultimately the solution is to stop putting fingers in the dike and take a broade r and different approach to providing care in the Philippines which would eliminate these and a significant

number of other problems of fraud and patient concerns. That approach would be t o contract for a local capitated PPO. It would save a significant amount of the current cos t and remove the current defrauders as players as well as eliminate the primary motivator tha t retirees have to use them; that being the fear of not being able to afford the upfront cost of a complex inpatient stay or not being paid because a provider is not certified. If this wa s done, the major area of concern would then be to insure that the contractor provided the care ag reed to within the guidance of the contract. But these issues would center on one contractor an d not thousands of individual providers as is now the case. James B. Houtsma