Fraud and abuse
Program integrity is a comprehensive approach to detecting and preventing fraud and abuse. Prevention and detection are results of functions of the prepayment control system, the post payment evaluation system, quality assurance activities, reports from beneficiaries and identification by a provider’s employees or Humana Military staff.
Defense Health Agency (DHA) oversees the fraud and abuse program for TRICARE. The program integrity branch analyzes and reviews cases of potential fraud (i.e., the intent to deceive or misrepresent to secure unlawful gain).
Some examples of fraud include:
- Billing for services, supplies or equipment not furnished or used by the beneficiary
- Billing for costs of noncovered or nonchargeable services, supplies or equipment disguised as covered items
- Violating the participation agreement, resulting in the beneficiary being billed for amounts that exceed the TRICARE allowable charge or cost
- Duplicate billings (e.g., billing more than once for the same service, billing TRICARE and the beneficiary for the same services, submitting claims to both TRICARE and other third parties without making full disclosure of relevant facts or immediate full refunds in the case of overpayment by TRICARE)
- Misrepresentations of dates, frequency, duration or description of services rendered or misrepresentations of the identity of the recipient of the service or who provided the service
- Reciprocal billing (i.e., billing or claiming services furnished by another provider or furnished by the billing provider in a capacity other than billed or claimed)
- Practicing with an expired, revoked or restricted license (An expired or revoked license in any state or US territory will result in a loss of authorized-provider status under TRICARE)
- Agreements or arrangements between the provider and the beneficiary that result in billings or claims for unnecessary costs or charges to TRICARE
Some examples of abuse include:
- A pattern of waiver of beneficiary cost-share or deductible
- Charging TRICARE beneficiaries rates for services and supplies that are in excess of those charged to the public, such as by commercial insurance carriers or other federal health benefit entitlement programs
- A pattern of claims for services that are not medically necessary or, if necessary, not to the extent rendered
- Care of inferior quality (i.e., does not meet accepted standards of care)
- Failure to maintain adequate clinical or financial records
- Unauthorized use of the TRICARE term in private business
- Refusal to furnish or allow access to records
Providers are cautioned that unbundling, fragmenting or code gaming to manipulate CPT codes as a means of increasing reimbursement is considered an improper billing practice and a misrepresentation of the services rendered. Such practices can be considered fraudulent and abusive.
Fraudulent actions can result in criminal or civil penalties. Fraudulent or abusive activities may result in administrative sanctions, including suspension or termination, as a TRICARE-authorized provider.
The DHA Office of General Counsel works in conjunction with the program integrity branch to deal with fraud and abuse. The DoD Office of Inspector General and other agencies investigate TRICARE fraud.
To report suspected fraud and/or abuse, call the Humana Military fraud and abuse hotline at (800) 333-1620.