Program integrity is a comprehensive approach to detecting and preventing fraud and abuse. Prevention and detection are a result of functions of the prepayment control system, the postpayment evaluation system, quality assurance activities, reports from beneficiaries, and identification by a provider’s employees or Humana Military staff.
TMA has a specific office to oversee the fraud and abuse program for TRICARE. The Program Integrity Branch analyzes and reviews cases of potential fraud (intent to deceive or misrepresent to secure unlawful gain). Some examples of fraud include:
- Billing for services, supplies, or equipment not furnished or used by the beneficiary
- Billing for costs of non-covered or nonchargeable services, supplies, or equipment disguised as covered items
- Violation of the participation agreement that results in the beneficiary being billed for amounts that exceed the TRICARE-allowable charge or cost
- Duplicate billings (e.g., billing more than once for the same service, billing TRICARE and the beneficiary for the same services, submitting claims to both TRICARE and other third parties without making full disclosure of relevant facts or immediate full refunds in the case of overpayment by TRICARE)
- Misrepresentations of dates, frequency, duration, or description of services rendered, or the identity of the recipient of the service or who provided the service
- Reciprocal billing (i.e., billing or claiming services furnished by another provider or furnished by the billing provider in a capacity other than billed or claimed)
- Practicing with an expired, revoked, or restricted license, since an expired or revoked license in any state or territory of the U.S. will result in a loss of authorized provider status under TRICARE
- Agreements or arrangements between the provider and the beneficiary that result in billings or claims for unnecessary costs or charges to TRICARE
The Program Integrity Branch also reviews cases of potential abuse (practices inconsistent with sound fiscal, business, or medical procedures and services not considered to be reasonable and necessary). Such cases often result in inappropriate claims for TRICARE payment. Some examples of abuse include:
- A pattern of waiver of beneficiary (patient) cost-share or deductible
- Charging TRICARE beneficiaries rates for services and supplies that are in excess of those charged to the general public, such as by commercial insurance carriers or other federal health benefit entitlement programs
- A pattern of claims for services that are not medically necessary, or if necessary, not to the extent rendered
- Care of inferior quality (does not meet accepted standards of care)
- Failure to maintain adequate clinical or financial records
- Unauthorized use of the term “TRICARE” in private business
- Refusal to furnish or allow access to records
Providers are cautioned that unbundling, fragmenting, or code gaming to manipulate the CPT codes as a means of increasing reimbursement is considered an improper billing practice and a misrepresentation of the services rendered. Such a practice can be considered fraudulent and abusive.
Fraudulent actions can result in criminal or civil penalties. Fraudulent or abusive activities may result in administrative sanctions, including suspension or termination as a TRICARE-authorized provider.
The TMA Office of General Counsel works in conjunction with the Program Integrity Branch in dealing with fraud and abuse. The DoD Inspector General and other agencies investigate TRICARE fraud.
To report suspected fraud and/or abuse, call the Humana Military Fraud and Abuse Hotline at 1-800-333-1620.
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