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CAMP FOSTER, Okinawa — The military’s Defense Health Agency said it is working with providers in the Philippines to fix claims issues that caused two key Angeles City hospitals to drop out of an experimental closed-network health insurance system started in the country earlier this year.

Improperly documented billing by some Philippine doctors and specialists held up overall claim reimbursements and led to Sacred Heart Medical Center and Angeles University Foundation Medical Center dropping out of the closed network last month, according to the agency.

Military retirees and dependents who live around the former Clark Air Base and are covered by Tricare health insurance were required to use the closed network beginning in January, but the loss of the two hospitals left Angeles City with no participating providers.

DHA said beneficiaries can now receive waivers allowing them to use other providers. Meanwhile, there is hope the two hospitals soon may return to the agency’s closed-network pilot project.

“We believe that once their claim issues have been addressed, they will decide to reconsider and again become part of the demonstration [project],” DHA spokesman Austin Camacho wrote in a statement to Stars and Stripes on Monday.

DHA contractor International SOS has put claims liaison officers in the Philippines to help the providers with properly filing claims and avoiding delays, according to Camacho.

Also, the contractor is “assisting the providers with reconciling their accounts and identifying claims previously paid but showing as unpaid in the providers’ accounting system,” he wrote.

The DHA demonstration project was designed to ease years of complaints from retirees that claim reimbursements were unfairly denied or delayed while also curbing rising program costs and fraud.

In the past, beneficiaries in the Philippines were required to fill out claims for medical services and send them to a Tricare contractor in the U.S. before being reimbursed. The closed network allows hospitals and doctors to directly bill Tricare and only charge beneficiaries their copay amounts.

But retirees have been skeptical of the DHA’s attempt at a closed-network insurance system since before it went online this year. Some raised concerns that billing and accounting systems are different among health care providers in the two countries and likely to create problems for the project.

DHA still plans to test the closed network during the next three years in the Philippines. New coverage areas are to be added in December and July.

“It is too early to determine the success or failure of the Philippine demonstration project,” Camacho wrote.

After it's fully implemented, the network will include most of the 11,000 military beneficiaries in the country and could become a model for DHA overseas insurance coverage elsewhere. Twitter: @Travis_Tritten


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