Americans spend more than $1 trillion every year on health care and an estimated 7 to 10 percent of this money is lost due to fraud and abuse schemes.

Fraud and abuse is an intentional deception or misrepresentation by an individual or entity that could result in an unauthorized TRICARE benefit or payment. Abuse is any practice that is inconsistent with sound fiscal, business or professional practice resulting in a claim, unnecessary costs or payment for services or supplies that are not medically necessary and appropriate and does not meet recognized professional standards for health care providers.

Depending on the circumstances, fraud and abuse can compromise the safety of your patients and the quality of care you provide. As a health care provider, you should be on the alert for situations where fraud and abuse can take place.

The following are common types of fraud and abuse:
 

• Up coding is billing for a higher level procedure than what was actually performed in order to obtain a higher benefit.
• Unbundling is billing with individual procedure codes instead of a single global code that clearly states an incidental procedure is included. For example: CPT code 71551 is an MRI of the chest including contrast material. Billing an additional supply code for the contrast material would be considered unbundling.
• Creative billing includes substituting covered diagnosis or procedure codes for a non-covered TRICARE procedure. For example: a patient undergoes a rhinoplasty, which is a non-covered cosmetic procedure, but TRICARE is billed for a septoplasty, which is a covered medical procedure for correction of a deviated septum.
• Medically unnecessary or inappropriate treatment applies when “extra” services are rendered and billed and there is no medical need for the service.
• Misrepresentation of provider information occurs when a non-authorized provider and non-authorized types of providers (for example, chiropractors) render services, but submit the claim under the identity of an authorized provider.
• Misrepresentation of clinical information involves manipulation of medical information about a patient in order to secure authorization for a surgical procedure or medical supply that would not have otherwise been covered.

If you suspect fraud or abuse, please contact the Humana Military Program Integrity Office at:
 

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In all cases, therapy services provided by pastoral counselors and licensed mental health counselors, which include family and child counselors and marital counselors (other than certified marriage and family therapist), require physician referral and supervision.

Services provided by alcoholism rehabilitation counselors are covered only when rendered in a TRICARE-authorized treatment facility and only when the cost of those services is included in the facility’s TRICARE-determined allowable charge.

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Updated August 6, 2007