The U. S. Embassy, Canadian Foreign Affairs Department and the British Foreign Service among other government agencies have warned of aggressive, unethical and potentially harmful treatment of patients who become seriously ill or injured while in Mexico (especially at Mexican tourist locations). To address this challenge, TPA Network offers this service to International Health, Accident and Travel Insurers; MGUs; HMOs; TPAs and Plan Sponsors having Insureds, Plan Participants or Members who have incurred claims for medical services delivered in Mexico.
In Mexico, and many other countries, most hospitals and healthcare facilities require payment “up front” prior to performing a procedure; accepting payment only in cash or via bank transfer or credit/debit card. Moreover, few accept foreign health insurance, Medicare, Medicaid or veteran health programs. As such, patients needing urgent or emergency care in tourist locations are often subject to unscrupulous practices and unethical treatment. Complaints documented by various entities include allegations of hospitals:
withholding care, or holding patients at hospitals against their will, pending payment;
withholding passports until payment is made;
obstructing needed medical evacuations;
price gouging and profiteering by charging highly inflated “tourist rates” to foreigners;
up-coding and unbundling of medical services;
failing to provide an itemized list of charges;
admitting people to the hospital when it is not necessary;
giving unnecessary or inappropriate medical treatment to increase revenue/salaries;
providing monetary incentives to ambulances for delivering patients to specific facilities;
giving monetary incentives to encourage more complex and expensive care, and
positioning hospital employees as in-house resort doctors to direct care to their facility.
In addition to putting a patient at risk, these activities unnecessarily cost patients and payors tens of millions of dollars annually. As a result of these practices, several Mexican hospitals have been, or are, under investigation for such activity and some have even been ordered to cease admitting new patients.
To make matters worse, the Usual, Customary & Reasonable (UCR) insurance construct is unique to the U.S. market (having its roots in the 1965 Social Security Act) and no such universal fee reference exists in Mexico. As such, defending against a fraudulent, unjustifiable or excessive claim is often very difficult.
To assist with this, TPA Network performs Medical Bill Review & Pricing Appropriateness Studies to protect patients and payors from being taken advantage of by unscrupulous providers who often submit claims that can be more than ten times a fair and acceptable rate.
Cost, Bill & Price Data Point Sources
The foundation of our service is based upon a highly defendable Reference Reimbursement Calculation that utilizes information available to TPA Network from these three distinct data sources:
Mexican Insurance Company Negotiated Rate Schedules
Few providers or health insurers in Mexico use any form of highly specific coding or billing scheme such as CPT, DRG or RBRVS. As such, the typical reimbursement methodology employed by most health insurers in Mexico involves the application of rather uncomplicated, unsophisticated fee schedules for various procedures, services, tests, studies, materials, supplies, equipment, etc. TPA Network has access to the fee schedules used by several of the leading Mexican health insurers and administrators. These schedules comprise a key element of our Reference Reimbursement Calculation.
Chargemaster Prices of the Leading Private Healthcare Network in Mexico
We have direct electronic access to the medical billing system of the largest private health-care network in Mexico. This network is comprised of more than two dozen full-service hospitals located in 16 cities having more than 2,500 beds and nearly 250 operating rooms. Its 15,000 medical providers treat nearly 125,000 hospitalized patients and more than six million outpatients each year. In addition to being very large and geographically diverse, this network is regarded as the premier national network in Mexico as it caters to both high-end national and international clientele. Indeed, with the exception of PEMEX and a few state and federal public healthcare programs, no other entity in Mexico transacts more direct patient care business than this entity. Access to this data provides authoritative, highly credible insight as to the cost of medical care delivery throughout Mexico.
International Traveler and Medical Tourism Data
Mexico is the leading destination for medical tourism and cross-border medical delivery. We have direct access to the medical claims and billing system of the highest volume medical tourist facility in the world (measured by number of patients served). Having transacted more international medical tourism business than any other commercial medical entity (treating more than 7,500 international patients to date) this facility works daily with international private patients; and U. S. and other foreign insurers. This data provides us with a unique vantage point with respect to both the cost structure used by a large scale medical tourism delivery system and the payment structure/fee schedules applied by many U.S and foreign insurers to reimburse providers in Mexico.
While it is this access to a broad base of cost, bill and price data that enables us to make reimbursement recommendations that are fully defensible, the essence of our Reference Reimbursement Calculation process is that it is objective, sensible, realistic and transparent.
Although other service vendors employ pricing guidelines and tactics designed to reimburse providers as little as possible, we do not subscribe to such practices. Instead, we always seek to make provider reimbursement recommendations that are viewed by payor, provider and patient alike as being fair, appropriate, usual, customary and reasonable; typically by considering and blending several data points. Indeed, our reimbursement recommendations are intended to satisfy 90% of similarly situated medical providers in a given locale (understanding that fees for certain services in tourist locations should be higher than standard).
Process & Method
Our Medical Bill Review & Pricing Appropriateness Studiesare always performed in a consistent manner and our findings are always legitimate and fully supported. It is because of this that we are always able to successfully defend our provider reimbursement recommendations.
Vendors of similar services typically have non-clinical employees perform their medical claim reviews. Others may use nurses or claims examiners. Some even boast of sophisticated algorithms designed to calculate an optimal payment amount. Our Medical Bill Review & Pricing Appropriateness Studiesare collaborative and comprised of multiple reviews by a team consisting of a medical coding specialist, a practicing nurse and an experienced medical claims examiner; all under the direction of a physician having relevant medical expertise in the subject practice area.
And, while we consult cost, bill and reimbursement data points from various sources in our evaluations and the development of our reimbursement recommendations, we do not rely upon complicated mathematical formulas or complex computer models. Instead we rely upon old-fashioned comparative computational analysis; non-automated human reasoning; and the exploitation of an abundance of experience, knowledge and expertise. We believe this process helps to strengthen the authority of our payment decisions and recommendation.
Our Medical Bill Review & Pricing Appropriateness Studiestypically include:
translating the entire claim (e.g., bill, medical records, support documents) to English;
converting charges from Mexican pesos to U.S. dollars;
a review of all bills, medical records and support documentation;
a line-by-line analysis of the submission to ensure that the provider billed appropriately;
identification of all duplicate, unnecessary, excessive, up-coded and unbundled services;
re-pricing each service line applying our Reference Reimbursement Calculation, and
a comprehensive report and database detailing all findings with support documentation.
Our reviewsprovide payors with a comprehensive analysis of all submitted charges and all the support necessary to successfully challenge charges and services that are incorrect, inappropriate or excessive. We perform our reviews in an independent, impartial, fair and honest way as we have no dog in the fight.