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Preventing fraud and abuse

Always review your Explanation of Benefits (EOB) and medical bills to ensure that the services billed were actually performed by the provider indicated and on the date specified. Keep track of every bill received or paid by TRICARE to make sure that you are not billed more than once for the same service. Do not be afraid to question your healthcare provider about the necessity of each procedure that is being ordered for you, especially if it seems excessive. Do not accept a discount of medical payments or the waiver of your co-payment unless you see the discounted amount reflected on your bill. If you have questions regarding your bill, please contact the doctor who provided the services.

All allegations of fraud and abuse are investigated to determine whether there is sufficient evidence to report the case to the government for further investigation. When submitting a report, you may remain anonymous; however, it may be beneficial to the program integrity unit to contact you for additional information, if possible. You can make a report online or by phone at (800) 333-1620

You may also choose to submit by mail. If submitting by mail, be sure to include the name of the subject to be investigated and their city and state, as well as a detailed allegation, how you became aware of the allegation and your phone number for follow-up purposes. This information should be sent to Humana Military, Attn: Program integrity, PO Box 2907, Louisville, KY 40201.

Program integrity

Healthcare 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. 

Most healthcare 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 seven to ten percent of the $3.6 trillion annual healthcare expenditures in the US 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. 

Crimes involving healthcare fraud lead to higher taxes, higher cost-shares for medical services and has the potential for false medical histories in patients' records. The program integrity department was formed to help combat this fraud and other attempted abuses committed within TRICARE. Our fraud investigators are committed to the prevention, detection and investigation of every alleged fraud and abuse case. 

Abuse is 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 healthcare providers.

Examples of fraudulent and abusive medical practices:

  • 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 noncovered services by using a different allowable description