Fraud happens when a person or organization deliberately deceives others to gain some sort of unauthorized benefit. Health care abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.
Beneficiaries are important partners in the ongoing fight against fraud and abuse. Because an explanation of benefits (EOB) is a tangible statement of services and/or supplies received, it is one of the first lines of defense against health care fraud. Each EOB provides a toll-free number to call if you have questions about services you believe are billed fraudulently, or you can access Humana Military's fraud and abuse reporting information. Through MyHMHS for Beneficiaries, you can use claims tools to view your EOBs, claims history, and track TRICARE costs paid. We strongly encourage you to read your EOBs carefully.
Report suspected fraud and abuse to Humana Military. See Figure 7.5 for details.
To report fraud or abuse regarding the pharmacy program, contact ESI:
You should maintain medical documentation, records, and health care history information from your health care providers for your own reference. Active duty service members should sign annual medical release forms with their primary care manager (PCM)—network or non-network—to allow information to be forwarded to civilian and military providers. If an active duty service member is reassigned to a new location, the PCM should provide complete copies of medical records and specialty and ancillary care documentation to the service member within 30 calendar days of the request.
