Tricare Philippine Demonstration Project

TRICARE has experienced dramatic increases in the amount billed for healthcare services rendered in the Philippines. Billings rose from $15 million in 1999 to $59 million in 2009 while the number of beneficiaries remained constant at about 11,000. Administrative controls such as the validation of providers, implementation of a fee reimbursement schedule, duplicate claims edits and the impact of the cost-shares and deductibles have limited actual TRICARE expenditures to $17 million in 2009. Fraud and abuse activities in the Philippines have been a growing concern that necessitated prompt investigation and actions to reduce the number of fraudulent or abusive incidences. Measures were taken to prevent or reduce the level of fraud and abuse against TRICARE while concurrent investigations and prosecutions were conducted. In April 2008, seventeen individuals were convicted of defrauding the TRICARE program of more than $100 million.
In an effort to control rising cost TRICARE will be implementing an alternative approach to providing healthcare services under the TRICARE Standard option in the Philippines. Over a 3 year period they will exercise their alternative approach in an effort to determine its validity. The new program is referred to as ―The DOD Tricare Demonstration Project for the Philippines‖, and has been posted in the Federal Register. A copy of the posting can be seen in this Bulletin‘s attachment entitled, ―DOD Tricare RP Demo Project‖. Under this demonstration, the overseas contractor in the Philippines (WPS) will establish a dedicated list of providers who will file their claims with the contractor and be reimbursed under an established fee schedule. As a result beneficiaries should have overall lower costs because these providers will no longer require payments at the time of service nor will they subject beneficiaries to balanced billing of charges. All TRICARE Standard beneficiaries residing in those geographic areas where WPS is able to develop a sufficient list of providers will be required to use these providers in order for their claims to be paid. Notice will be provided to the beneficiaries informing them of the areas participating and not participating in this demonstration. [Source: 60008 Federal Register / Vol. 76, No. 188 / 28 Sep 2011 / Notices ++]