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Fraud and Abuse Overview
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Why Program Integrity?
Most health care providers subscribe to the highest code of ethical standards. However, as in any large population, some individuals intentionally seek to defraud the system. In fact, estimates indicate that between 7% to 10% of the $2.2 trillion annual health care expenditures in the United States are fraudulent.
*By actively coordinating with government officials and other insurers, our fraud investigators work to identify and investigate every individual attempting to defraud or seriously jeopardize the quality of patient care. Why? Because crimes involving health care fraud lead to:
HMHS formed the Program Integrity Department to help combat this fraud and other attempted abuses committed within the TRICARE Health program. Our fraud investigators are committed to the prevention, detection, and investigation of every alleged fraud and abuse case.
DID YOU KNOW...
- that Health Care Expenditures in the U.S. are approximately $1.1 Trillion annually?
- this is a very alluring target for those who would choose to perpetrate fraud schemes!
- that every dollar lost to Health Care Fraud is one dollar less for national defense?
- that Health Care Fraud is defined as intentionally misrepresenting a service or supply in order to receive a higher benefit?
- that the crime of Health Care Fraud is the second priority of the United States Department of Justice?
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What is Health Care Fraud?
Health care fraud is defined as: "An intentional act of misrepresentation or deception that results in a higher benefit to the beneficiary, the provider, or some other entity."
What is Abuse?
Any practice that is inconsistent with accepted and sound, fiscal business, or any professional practice which results in a TRICARE claim cost for TRICARE payment for services or supplies that is: (1) not within the concepts of medically necessary and appropriate care or (2) fails to meet professionally recognized standards for health care providers.
Examples of Fraudulent and Abusive Medical Practices Include:
- Charging more than once for the same service (double billing).
- Charging for services never performed or medical equipment/supplies never ordered.
- Performing inappropriate or unnecessary services.
- Offers of free services or medical equipment in exchange for your policy number.
- Providing lower cost or used equipment while billing TRICARE for higher cost or new equipment.
- A supplier completing a Certificate of Medical Necessity form for a physician.
- Awareness of an ineligible beneficiary on someone's plan, i.e. girlfriend listed as a spouse.
- A provider solicits a "free" consultation or service, which is then billed to TRICARE.
- Someone offering you an incentive to sell your insurance information, i.e. Policy numbers.
- A provider offers to conceal non-covered services by using a different allowable description.
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