TRICARE Fraud Alert

ANTI-FRAUD AND AUDIT STANDARDIZATION PROGRAMS TEMPLATE


E1.1    ANTI-FRAUD AND AUDIT STANDARDIZATION PROGRAMS

The MTFs must standardize their implementation of an Anti-Fraud Program to ensure uniformity across the Military Health System (MHS).  The following template provides guidance for implementing an MTF anti-fraud program.

Template for 5.1.1.  Establish an anti-fraud program documenting the roles and responsibilities addressing civilian contracts for health care providers to deliver health care at their MTFs

    a.  Designate roles and anti-fraud responsibilities for:  (1)  Establishment of safeguards in development of the civilian provider contracts; (2)  Establishment of the internal management program;  (3) Establishment of the anti-fraud training protocol;  (4) Establishment of the desk procedures and (5) Establishment of provider certification protocol. 

b.  When allegations of egregious billings or potentially fraudulent or abusive situations are first identified, review to eliminate obvious administrative errors.  

    c.  After possible administrative errors have been ruled out: 

•    Review to determine the probable method of fraud/abuse.
•    Look at entire picture to determine if a pattern exists.
•    Determine potential impact of erroneous payment of MTF funds (e.g., analysis and
    manipulation of health care data).

d.   Refer identified cases to TMA Program Integrity.   Referral content includes:

•    Provider’s name
•    Summary of Allegation(s)
•    Source(s) of Information
•    Monetary impact on MTF funds
•    Copies of Audit Findings and Other Relevant Supporting Documents

    e.  For guidance, technical expertise and referrals contact:

Program Integrity Office
TRICARE Management Activity
16401 East Centretech Parkway
Aurora, CO 80011-9066
(303) 676-3478

Template for 5.1.2.   Develop an internal management control program that fosters oversight of contracted civilian health care providers.

    a.  The type of fraud in the MTF is dependent on the type of contract entered into with the provider of care. 

•    If the agreement is set up on a per services basis, then controls need to be in place
for identifying billing for excessive services, upcoding, billing for services not rendered, etc. 
•    If the agreement is set up on a monthly salaried basis with no financial incentive
to provide or not provide services, then controls need to be in place to ensure services are provided for the period of payment, i.e., MTF supervision, clinic logs. 

Template for 5.1.3   Develop an anti-fraud training protocol for personnel to educate them in the in the detection of potential fraud or abuse situations and how individuals may identify and report allegations. 

    a.   Keys to an effective training & education program:
•    Provide mandatory fraud/abuse training for MTF personnel, annually.  Training
should include informing personnel of latest fraud schemes and where to report them.
•    Include fraud/abuse articles in internal newsletters. 
•    Encourage participation in training opportunities – e.g., National  TRICARE
Health Care Fraud Conference.
•    Educate MTF personnel on where to report fraud/abuse.
•    Establish and maintain contacts with other MTFs, TMA PI, and others who can
assist in anti-fraud efforts.
•    Get involved in meetings with QA staff and Clinical Management personnel.

    b.  Recommendations for implementing an effective training and education program:
•    Take advantage of articles, tips, & other ideas.
•    Use the news articles on the TRICARE website, www.TRICARE.osd.mil\fraud.
•    Use the web to locate fraud sites – these sites contain invaluable information. 
•    Take advantage of TMA PI’s expertise.
•    Explain anti-fraud efforts taken, the tools used to identify cases, successes
    (indictments & convictions), current issues, etc.
•    Provide positive feedback when employee identifies a potential fraud/abuse case.
•    Use your website to disseminate information to beneficiaries.
•    Solicit “requests” for suggested fraud/abuse articles and topics for upcoming
    training. 

    c.  The Benefits of Publicity:
•    The deterrent effect – letting people who commit fraud know that you are
        watching.
•    It informs the public about the pervasive nature of the problem and assists in
gaining their support.
•    Creates a positive image for MTFs who want their beneficiaries to know they are
doing the right thing by fighting fraud.
•    Educates beneficiaries by providing information about fraudulent/abusive
practices and how to report such practices.

Template for 5.1.4.  Develop and standard-operating-procedures(SOPs) that include methods for identifying situations involving unusual patterns of care, overutilization of services, suspected billing practices or other unusual practices.

a.  Identify patterns of probable fraudulent or abusive practices by manipulating and
analyzing health care data associated with type, frequency, duration and extent of services.

b.  Maximize use of existing data systems (SIDR, SADR, TEDS) to monitor workload
trends to identify potential practice anomalies.  Enables handling of multiple cases with minimal resources.

c.  Establish procedures of identifying which providers to audit, i.e., top 3 highest
reimbursed providers, providers with suspect patterns of billing, providers who are paid on a fee-for-service basis, etc.

d.  Determine type of audit most appropriate for case, i.e., calendar audit (valid for
identifying cases in which more services billed for than physically possible to perform); probe audit  (looking at handful of records to determine if allegations have any basis); or statistically valid sample (useful to determine dollar loss to MTF and losses can be extrapolated to the universe). 

d.    Examples of Fraud/Abuse Situations in the MTF (resource sharing/clinical support
    providers or contracted providers)

•    Upcoding actual services rendered (documenting  higher level of service than
rendered)
•    Billing for services provided by MTF military personnel, laboratory or x-ray
department
•    Using Government facilities for private patients, i.e., lab, x-ray department
•    Using non-authorized or non-licensed staff to render care but represents oneself as
the provider of that care
•    Gains access to pharmaceuticals, supplies, and equipment for personal use and/or
monetary gain.
•    Referrals of patients to provider’s own civilian practice
•    Misrepresentation of credentials
•    Lax management of DD 250 for contract providers
•    Providing unauthorized services/benefit (resource sharing/clinical support)
•    Explanation of Benefits (EOBs) sent to provider office/addresses
•    Billing for more visits/workload than possible to accomplish

Template for 5.1.5.  Ensure all provides are credentialed and privileged to practice in the state in which the services are being provided and are not on the HHS-IG or TRICARE sanction/suspension list.

           a.  Establish and maintain liaison with the state licensing department to confirm provider
licensure and to receive notices of any actions related to termination, revocation or restriction of a provider’s license to practice.

           b.  Arrange to receive and review the monthly listing available from TMA-PI identifying
the HHS-IG sanctions and reinstatements.  Reference the HHS-IG-sanction link available on the “links” to the TRICARE Fraud Webpage, www.TRICARE.osd.mil/fraud which allows for quick identification of sanctioned providers by entering basic identification information. 

           c.  Federal legislation prohibits payment of sanctioned providers by any federal or state
entity.  Notify TMA-PI if MTF personnel become aware of any situation in which a sanctioned provider is prescribing or rendering services to military personnel or their families.  See Special Advisory Bulletin on “The Effect of Exclusion from Participation in Federal Health Care Programs at the HHS-IG web site:  www.oig.hhs.gov/fraud/docs/alertsandbulletins 

d.    TRICARE has the right to sanction or suspend providers and that information
concerning those actions are posted at:  www.TRICARE.osd.mil/fraud.  Procedures should be in place to ensure no agreements are made with any sanctioned or suspended providers.   Language should be included in the agreement that any adverse action against the provider such as HHS/TRICARE suspension or sanction action or adverse state licensure action resulting in restricted or revoked license to practice is cause for immediate termination of the contract. 


Daniel S. Abrahamian
TRICARE Fraud Alert
FEELMYFLAME