Why Program Integrity?
What is Health Care Fraud?
What is Abuse?
Examples of Fraudulent and Abusive Medical Practices
Understanding my Explanation of Benefits (EOB)
Guidelines to Help Prevent Fraud and Abuse
How to Report Fraud and Abuse
Additional Resources on Fraud and Abuse

Humana Military Healthcare Services (HMHS) is committed to the prevention, detection, investigation, and referral for prosecution of every alleged case of fraud and abuse.

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 $1.1 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:
  

• Higher taxes
• Higher cost shares for medical services
• The potential for false medical histories in patients' records

Back to Top

Back to Top

Back to Top

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.

Back to Top

Always review your Explanations of Benefits (EOBs) and medical bills to ensure that the services billed were actually performed by the provider indicated and on the date specified. You can learn more about the information contained within your EOB  visiting the PGBA Web site. 

Should you have a question about your bill, contact the doctor who provided the services, or the PGBA Claims Line at 1-800-403-3950.

Back to Top

Guidelines to Help Prevent Fraud and Abuse:
 

• Keep track of every bill received or paid by your insurance provider to make sure that you are not billed more than once for the same service.
• Do not be afraid to question your health care 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 are assured that the discounted amount is reflected on the billing for your health care provider.

Back to Top

If you, in good faith, have a suspicion that a TRICARE provider or a beneficiary has committed an act of fraud or abuse, you may report this suspicion to HMHS Program Integrity.  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 may make a report through any of the three resources listed below:

Back to Top

Additional Resources on Fraud and Abuse:
 

Back to Top