Tricare Philippines Newsletter 12009
Using the Certified Provider List
Addendum to Current Understanding of the Provider Certification Process, Newsletter 12008
Recent input from a TMA employee addressed an issue reported by some retirees where International SOS (ISOS) made an appointment with a provider for certification but failed to appear at the appointed time. In some cases it was reported that they appeared at the clinic, unannounced, a few weeks later. Apparently the point of this approach and another method addressed of simply walking into the building where the clinic is located hoping to be there when the doctor holds clinic or then returning again unannounced at a later date is a requirement put in place by the Program Integrity office of the TRICARE Management Activity (TMA), presumably in an attempt to catch local providers who are attempting to have their two room clinic designated as a medical center or a large provider group by placing beds in the clinic or having multiple other physicians present and representing themselves as part of the physician group. Program Integrity believes that there is major ongoing fraud by providers and beneficiaries as demonstrated by their latest comments to my congresswoman stating that because of this Philippine fraud, 64% of all providers and 77% of all beneficiaries are on what they call Prepayment Review.
Because of this recent new approach to certification, beneficiaries may want to explain that the ISOS staff may appear, without warning, to discuss certification and obtain the required documents instead of calling or sending a letter. Or may contact them and make an appointment but fail to show at the appointed time and instead show up weeks later unannounced.
Considerations when using the Certified Provider Lists
Under current policy ISOS is required to provide an updated list to TMA for publication on their TRICARE Area Office – Pacific web page on the 1st and 15th of the month unless it falls on a weekend or holiday in which case it should be posted the next workday.
If a provider is removed from the list, any claims for care provided after the posting of the list where they were removed will be denied. Therefore it is important to review the list at least periodically to determine if your providers are still on the list. To assist with this we provide a supplemental spreadsheet for each one of the posted lists. This spreadsheet provides listings of newly added and removed providers as well as separate listings of providers that were already on the prior lists but where ISOS made corrections to their address or city. None of this information is provided by TMA or ISOS. The spreadsheet also contains information about any significant issues found with the data to assist in finding providers. All of these supplemental spreadsheets can be viewed by going to our document, Supplemental Spreadsheets for the Philippine Bi-weekly Certified Provider List, and selecting the appropriate sheet based on the date of the Certified Provider List of concern.
While the list contains significant data errors and duplicate records some improvement has been made in recent months. The most noteworthy are the addition of separate fields for province and city and specialty. We pushed for these and other improvements for many years and finally some of them are starting to be implemented.
How should I try to find providers on the list?
There are three options available to access or obtain the list on the web page. Two options allow the list to be downloaded and the third to do some basic searches of the list on the web page.
We do not recommend using the search option on the web page due to the amount of bad data that exists in many of the fields. The search uses standard computer search technology which cannot overcome the data errors so search results are suspect. The search options do not allow for searches involving fields that are blank which means those records are never seen. It also provides search options in only three of the eight fields.
Of the two download options the first listed is “PDF” and not recommended either for two reasons. The first is the file is extremely large, 13.9 MB vs. 1.7 MB for the spreadsheet. For those with slow internet connections the file could take hours to download. Second, special software is needed to properly search a “PDF” file. While there are a number of packages, some free, the methods used for searches are limited and difficult to use for our purposes.
The last option to download an Excel spreadsheet is the recommended option. The downloaded spreadsheet can then be sorted and filtered to assist in finding providers. It can be opened using Excel or other free software packages. One of the more common free packages is known as “Open Office”. For a comprehensive list of alternatives go to the Wikipedia page, List of spreadsheet software.
Some examples of bad data to consider when doing a search:
- Provider names are generally run together with no spaces, example ACORDA,VIOLETA,N,MD, but sometimes they add spaces. Provider names are sometimes entered with last name first and at other times first name first and yet other times with Dr. as the start of the name. So unless you already know how they entered the provider’s name in the database your search by name down the alphabetical list may prove to be a waste of time.
- Provinces may be spelled two or more ways or left blank. Using the province pick list will not show those providers who are from the province but where the field is blank. But using the dropdown Auto Filter in Excel will show misspelled entries which can be included in a search.
- Cities may be spelled two or more ways, some may be listed with “City” as part of the name and some may not for the same city. Example Baguio and Baguio City. Others are left blank. But using the dropdown Auto Filter in Excel will show misspelled entries which can be included in a search.
- Specialty listings are inconsistent and sometimes blank. Specialty searches are not available on the web.
- Address listings for providers where the city or province is left blank many times contain the province or city. So using the Excel Auto Filter “Text Filter contains” option filled in with the province or city may allow you to find providers not otherwise identifiable as from that province or city.
Below are some tips on doing searches for providers.
If you know the last name of the provider you can do a search on the Provider Name filed for just the last name. This will create a list of all providers with that name somewhere in their name to be listed. This would be done with the Excel Auto Filter “Text Filter contains” option as mentioned above. Then look down the list of names and find the specific provider you are looking for. Another option is to do sorts by Provider Province or Provider City to obtain a list of providers that match your criteria. The drawback to this approach is providers in the given province or cities that have blank fields will not show up so you will miss them. However you can do a second search again using the Excel Auto Filter “Text Filter contains” option on the address field, again as described above.
Learn how to do searches using the Excel Auto Filter options.
The link explanations and examples can be applied to any column and will have to be repeated on both tabs of providers. There is one that is entitled “MM-DD-YY Certified List” where MM-DD-YY represents a date and a second entitled “MM-DD-YY Not used in 2 years”. Of note is the number of data errors increases significantly with the data contained in the second tab.
These links refer to Excel. If you use another software package the instructions may not apply but a search of the internet is likely to turn up similar examples and explanations for the other software package.
Using Auto Filter and Sort in Excel (YouTube)
How to Use Excel Filtering to Find Data Fast
Excel AutoFilter Makes Spreadsheets More Useful
Ribbon Interface - Excel 2007 and later
Menu Interface - Excel 2003 and earlier
The next newsletter will address how to file a claim for the hospital portion of hospitalization. This portion of a hospital claim is generally simple and results in the full billed amount being allowed resulting in full 75% reimbursement when submitted properly. However our experience is many are unsure what to do and don’t file claims or file them improperly based on our review of the claims database. Since these claims represent large sums of money, a little time invested in understanding the requirements will result in large dividends.
Share this newsletter with other beneficiaries
Forward this newsletter to others you feel might benefit from them so they can sign up as well. If you represent an RAO or service organization let your members know so they can sign up. Sign up link
If you are on Facebook share this newsletter with your friends.