Health care fraud and abuse are costly and dishonest, and serious cases may result in criminal investigation and prosecution. Identifying and preventing fraud and abuse helps save valuable benefit dollars and ensures TRICARE beneficiaries receive the quality of care to which they are entitled.
 
Fraud is defined as the intentional deception or misrepresentation of facts, resulting in unauthorized benefits or payments. When undetected, fraud can negatively impact patient care.
 
Some examples of fraud include the following:

• Billing for services at a higher level than provided or necessary
• Collecting amounts from TRICARE beneficiaries that exceed the TRICARE-allowable charge
• Failing to disclose coverage under other health insurance
• Falsifying claims or medical records
• Falsifying eligibility
• Misrepresenting the dates, frequency, duration or description of services rendered
• Misrepresenting who provided the services
• Submitting claims for services not rendered

Abuse is practicing improper or inappropriate actions, having less than acceptable standards of professional conduct or performing services that are not medically necessary.
 
Some examples of abuse include the following:

• A pattern of claims for services that are not medically necessary
• A pattern of waiving cost-shares and/or deductibles
• Failure to maintain adequate medical or fi nancial records
• Improper billing practices
• Refusal to furnish or allow access to medical records

To report suspected fraud or abuse by another provider or a TRICARE beneficiary, call the Humana Military Healthcare Services, Inc. (Humana Military) Fraud and Abuse Hotline at 1-800-333-1620. You can also access the Humana Military Program Integrity Referral Form online or contact the TRICARE Program Integrity Office at:
 
TRICARE Management Activity
Attn: Program Integrity
16401 East Centretech Parkway
Aurora, CO 80011-9066
 
Fax: 1-303-676-3981
Online: www.tricare.mil/fraud
E-mail: fraudline@tma.osd.mil
 
TRICARE strives to provide quality, affordable health care to all of its benefi ciaries. Preventing fraud and abuse is one way to keep costs down and ensure beneficiaries receive the optimal care they deserve. We ask for your cooperation in preventing and reporting fraud and abuse.

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