Through both troubled and peaceful times, one goal of the Department of Defense’s (DoD) Military Health System (MHS) that remains constant is the commitment to providing cost-effective quality health care to its 8.9 million beneficiaries. However, health care fraud and abuse constantly impede the ability to realize that goal.

It’s easy to see why when you consider that the National Health Care Anti-Fraud
Association estimates that 3 percent, or $42 billion, of what Americans spend annually on health care is lost to fraud.

The TRICARE Management Activity (TMA) Program Integrity Office (PI) in Aurora, Colo.,
is the central coordinating agency for investigating cases of alleged fraud and abuse committed against the DoD MHS’ TRICARE Program.

More than 15 years of experience has taught TMA PI (known as the TRICARE Fraud Squad) that to adequately
address the fraud and abuse problem requires teamwork and working relationships between TRICARE, its contractors,
law enforcement, the Department of Justice (DOJ) and those in the public and private sectors. In cooperation with investigative agencies and DOJ between 1999 and 2003, TMA PI has helped return more than $25 million to DoD.

Operation TRICARE Fraud Watch, launched in 1999, has contributed to enhanced information sharing and in the
creation of a fraud section of the TRICARE Web site (www.tricare.osd.mil/fraud). Operation TRICARE Fraud Watch
also has enforced an aggressive regional contractor oversight plan that emphasizes a commitment to the detection
and referral of fraud cases to TMA PI, as required by each contract.

Clinicians play a key role in the fight against fraud and abuse because they are on the front line and are more likely to detect aberrant or dangerous practices that would otherwise not be identified or detected.

Take the case of the pharmacist with pharmacies in Kansas and Missouri who was convicted of diluting cancer chemotherapeutic treatments sold to physicians’ offices. The scam went undetected for 10 years until an oncologist became suspicious.

Concerned about patient welfare, the oncologist personally paid for testing the IV chemotherapeutic solution ordered
from the pharmacy. The test results revealed that the solution had been prepared at 30 percent of the strength ordered. Federal agents arrested the pharmacist after the oncologist notified them of the test results. The pharmacist pled
guilty to 20 charges and was sentenced to 30 years in prison.

Such situations cannot always be readily identified by fraud units or the patients involved. The involvement of clinicians
is vital because they are in the position and have the knowledge to detect and report problems.

Humana Military Program Integrity has been the recipient of every TMA Program Integrity Contractor of the Year Award. Humana Military PI takes an aggressive, proactive approach to ferreting out fraud and abuse.

Allegations can be reported to Humana Military Program Integrity Office, 500 W. Main Street, 19th Floor, Louisville, KY, 40202 or faxed to 502-580-3401.