TRICARE Area Office-Eurasia Africa MedXellence Briefmedxellence.pesgce.com/presentation_pdf/07-17-2017... · “Medically Ready Force…Ready Medical Force” 1 TRICARE Area Office-Eurasia

“Medically Ready Force…Ready Medical Force” 1

TRICARE Area Office-Eurasia AfricaMedXellence Brief

LCDR KC Nilsson, MSC, USNChief, Business Operations, TAO-EA

August 2017

“Medically Ready Force…Ready Medical Force”

Disclosure

Presenter has no financial interest to disclose.

This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with the MedXellence Program. PESG, and MedXellence Staff, and accrediting organization do not support or endorse any product or service mentioned in this activity.

PESG and MedXellence Program staff has no financial interest to disclose.


Objectives

• Describe what a TRICARE Area Office (TAO) is and what we do

• Discuss the complexities of providing the TRICARE benefit in an overseas environment

• Describe network quality assurance

• List TAO – Eurasia Africa and TRICARE Overseas Program (TOP) resources


What is the TRICARE Overseas Program?

• TRICARE is a health benefits plan for network/purchased care• Not “insurance,” but… a BENEFIT directed by law.

• 4 regions with 4 separate Managed Care Support Contractors

• 3 stateside regions (North, South, West) – Managed Care Support Contractors

• 1 overseas region divided into 3 overseas areas – Healthcare Support Services Contract (Eurasia-Africa, Pacific, Latin America & Canada)

• TRICARE Overseas Program (TOP) = TRICARE OCONUS

• TOP Prime (MTF-based), TOP Prime Remote (non-MTF based)

• TOP Standard (eligible beneficiary not enrolled to TOP Prime/Remote)

• International SOS (Intl. SOS) for all overseas care


The TRICARE Area Office – Eurasia Africa, in collaboration with MTF commanders, is responsible for the development and execution of an integrated plan for the delivery of health care in the Eurasia-Africa area.

Ensure accessible, safe, quality purchased health care services for ALL entrusted to our care through administration of a coordinated, cost effective, multi-service health plan.

TAO Eurasia-Africa Mission

“Medically Ready Force…Ready Medical Force” 6

Program Operations

DivisionCAPT Christine Mankowski

USN, MSC

Clinical Operations

Division

Medical DirectorLTC Randal Freeman

USA, MC

Business Operations

DivisionLCDR KC Nilsson

USN, MSC

TAO- EA Executive Director

CAPT Christine Mankowski (Acting)

Number of Staff

6/6 Military

1/1 GS

3/3 Local Nationals

1 Contractor

Senior Enlisted AdvisorMSgt Michelle Wilkerson, USAF

Intl SOS Regional Manager

William Cochran

Frankfurt, DE

Intl SOS Regional Director

Sean Bevington

London, UK

TAO – Eurasia Africa Sembach Germany

Director, DHA

VADM Raquel Bono

Chief, TOPO

Cindy Dilorenzo

Director, TRICARE Health Plan

Ken Canestrini

Director, Health Plan Execution and Operations

Kathy Larkin


TAO – Eurasia Africa Functions

• Government oversight of TOP contractor, Intl. SOS (London), for AOR

• Includes TOP quality and CLINICAL quality

• Contractor audits, network fraud identification

• TOP Prime Remote support (POC Training, out of area care authorizations)

• AOR medical capabilities consultants (e.g., EFMP, OSS)

• MTF education (providers, leaders, BCACs/referral management)

• Beneficiary Education

• Liaison between Intl. SOS and MTFs/government organization’s

• Ensure Network Adequacy

• Expectation Management regarding TOP contract/program


TAO - Eurasia Africa (non) Functions

• NOT contingency planners for Services, COCOMs• But do educate/consult on TOP utilization in operational setting

• Intl. SOS does not provide contingency care or tactical evacuation

• Direct MCRs by Intl. SOS for TOP Prime Remote planning

• DO NOT run the MTF TRICARE Service Centers (TSCs)

• We DO NOT arrange/pay medical TDY (Services do) or coordinate aeromedical evacuation (TPMRC-E, JPMRC)

TAO - Eurasia Africa - Who We Serve

• TRICARE in the Eurasia-Africa AOR:

• 175,000 eligible beneficiaries in Eurasia-Africa

• 163,579 enrolled or empanelled for care

• 146,221 Prime (136,090) and Prime Remote (10,131)

• 17,358 TRICARE PLUS

• Additional Deployed, TAD and personnel on leave

• Primary Healthcare Delivery Sites in Eurasia-Africa

• 23 Military Treatment Facilities (MTF’s)

• 156 Designated Remote Sites

• 89 Non-Designated Remote Sites

Data Source: M2, as of: 1 Jan 2016 “Medically Ready Force…Ready Medical Force”


TOP Beneficiary Types

11

TRICARE is a Global Enterprise

Green = TAO-EA AOR


12

TAO – Eurasia Africa AOR

98 Countries, 245 remote sites / embassies, & 23 Military Treatment Facilities (MTFs).

6 countries account for nearly 90% of all the beneficiaries.Germany, Italy, Spain, England, Turkey, Belgium

TRICARE Eurasia Africa AOR


TOP Contract vs. Managed Care Support Contracts

TOP Contract Managed Care Support Contracts

Potential for varying number of eligible beneficiaries

Number of eligible beneficiaries more stable

3 Geographical areas 3 Geographical areas

163 Countries 1 Country

99 Languages 1 Language

134 Currencies 1 Currency

Accommodates a wide range of cultural differences

Health care delivery is largely standardized

13


TOP Contract vs. Managed Care Support Contracts

TOP Contract Managed Care Support Contracts

Contractor codes claims Provider codes claims

Bills are itemized based on country’s laws/practices

Bills are all inclusive

Multiple billing practices Rendering provider files claim

Foreign currencies 134 1 Currency

Timely filing – 3 years * (Except PR & US Territories)

Timely filing – 1 year

Payment at time of service generally expected

Majority of providers do not expect payment at time of service

Proof of Payment Required Proof of Payment – not normally required

14


TRICARE Dental Program

• TRICARE Dental Program (Active Duty Family Members) – United Concordia

• Patients can choose to visit any civilian Dental provider

• TOPD (Tricare Overseas Preferred Dentist) – Patient pays only the co-pay and provider bills United Concordia for the balance

• Orthodontic treatment is the only benefit that requires pre-authorization by TAO-P, $1,750 lifetime max

• Active Duty Overseas Remote Dental Program (Active Duty Military) – International SOS

• All dental care needs to be approved and coordinated through International SOS

• Specialty care and complex treatment plans above $750 require approval by TAO-EA via International SOS

• Must use International SOS approved providers


Network Quality Assurance

• The TOP Contractor is responsible for researching & reporting to DHA when a serious reportable event (SRE) occurs in a host nation facility/host nation provider’s office

• Refer to the most current National Quality Forum (NQF) Serious Reportable Events and Agency for Healthcare Research and Quality (AHCRQ) Patient Safety Indicators for what is considered a SRE


Quality Committee

• Intl. SOS Regional Quality Committee

• Members from Intl. SOS/TAO-EA/DHA

• Discuss/Track/Trend PQIs, QIs, & Grievances

• All PQIs thoroughly researched and presented

• Intl. SOS determines if QI exists

• If QI, Severity of Level assigned/need for CAP determined

• Final Determination to TAO-EA Medical Director only

• Limited feedback to MTF CC* • Open, Closed, Provider removed from network

• *unless impacts MTF internal QA, e.g. credentialing


Network Care Grievances

• Anyone can submit a grievance

• International SOS investigates all network grievances

• Submitting a grievance:

• Email: [email protected]

• Online:

• http://www.tricare-overseas.com/provider_grievances.htm

• Copy the TAO-EA Medical Director on all SREs

• [email protected]

• Compliments can also be submitted online!

mailto:[email protected]

http://www.tricare-overseas.com/provider_grievances.htm

mailto:[email protected]


In conclusion….

• The overseas environment is complex

• POCs, MTFs, TAO, International SOS

• We are all on the same team!

• There are numerous resources to help you do your job

• Grievances, complaints, compliments…..share them!


Useful Resources

• TOP Overview Brief

• www.tricare.mil/briefings

• TRICARE Publications

• www.tricare-overseas.com

• TOP Beneficiary Handbook

• TOP Guidebook

• TOP Passport

• TRICARE Wallet Card

• TRICARE Overseas Health Matters Newsletters

http://www.tricare.mil/briefings

http://www.tricare-overseas.com/


TOP Online Resources

• Download a TOP Country-Specific Wallet Card: www.tricare-overseas.com/contactus

• Frequently asked questions: www.tricare.mil/faqs

• Provider search: www.tricare-overseas.com/ProviderSearch

• milConnect: http://milconnect.dmdc.mil

• E-mail updates: www.tricare.mil/subscriptions

• Publications: www.tricare.mil/smart

http://www.tricare-overseas.com/contactus

http://www.tricare.mil/faqs

http://www.tricare-overseas.com/ProviderSearch

http://milconnect.dmdc.mil/

http://www.tricare.mil/subscriptions

http://www.tricare.mil/smart


• Regional Program Director: Mr. Sean Bevington

• Regional Program Manager: Mr. William Cochran

• Regional Medical Director: Dr. Edward Bebb

• TRICARE Overseas Regional Call Center Eurasia Africa

• From US: 1-877-678-1207 (+44-20-8762-8384)

• From Germany: 0800-589-1599, 0800-723-4214

• www.tricare-overseas.com/ContactUs/default.htm

International SOS(Regional Medical Assistance Center: London)

http://www.tricare-overseas.com/ContactUs/default.htm


If you would like to receive continuing education credit for this activity, please visit:

http://medxelence.cds.pesgce.com

Obtaining CME/CE Credit

http://medxelence.cds.pesgce.com/


Questions?


Back-up Slides


TAO - Eurasia Africa - Challenges

• Language Barriers

• Cultural Differences

• Expectation Management (especially in remote areas)

• Overseas Screening / EFMP

• Deployable Troops

Current 10 Largest Prime Remote Sites in Eurasia-Africa


City, Country Enrollees Notes of InterestDoha, Qatar 754 3 population groups (Al Udeid AFB, Embassy, CAS)

Lajes, Portugal 532 Ex-Air Force MTF Site, clinic closed 4th of July 2015

Abu Dhabi, United Arab Emirates 431Al Dafra Air Base (USAF 380th Air Expeditionary Wing) plus Embassy personnel

London, UK 409Embassy-based Beneficiaries plus Northwood NATO base personnel

Riyadh, Saudi Arabia 356 Eskan Village AFB plus Embassy personnel

Garmisch, Germany 339 Large Army Garrison (USAG Bavaria)

Volkel, Netherlands 276701st Munitions Support Squadron of the USAF 52nd Fighter Wing at Spangdahlem

Gaziantep, Turkey 274 Very remote mission near the Syrian border

Ghedi, Italy 261704th Support Squadron of the USAF 52nd Fighter Wing at Spangdahlem

Moron, Spain 250 GSU of the USAF 86th Ops Group (Ramstein)

Documents

TRICARE Area Office-Eurasia Africa MedXellence Briefmedxellence.pesgce.com/presentation_pdf/07-17-2017... · “Medically Ready Force…Ready Medical Force” 1 TRICARE Area Office-Eurasia