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How fraud affects you and what you can do to prevent it

How does fraud affect me?
What can I do to prevent fraud?
Frequently Asked Questions about fraud
Fraud and the Internet
Related Links

What is fraud?
When people intentionally deceive or misrepresent the healthcare services they have given or received to gain unauthorized TRICARE payment, they commit fraud. Both doctors and beneficiaries can be guilty of fraud. The lists below are not all-inclusive, but some examples of fraud by providers include:

Billing for services the doctor didn't provide.
Accepting kickbacks.
Embezzling.
Prescribing services not medically necessary.

Some examples of fraud by beneficiaries include:

Visiting emergency rooms excessively seeking controlled drugs.
Not reporting other health insurance.
Altering bills or receipts.
Submitting claims for a grandchild who is ineligible.

How does fraud affect me?

Healthcare fraud hurts everyone. Your taxes soar because of fraud in government programs such as Medicare, Medicaid and TRICARE. According to a May 1992 report to Congress, the General Accounting Office estimated that healthcare fraud accounts for up to 10% of our annual healthcare spending. In 1992, that would equal $84 billion.
Because there is no way to tell how much fraud actually occurs at any time, the exact cost of fraud is difficult to assess. According to the National Health Care Anti-Fraud Association (NHCAA) Web site, "Most NHCAA private insurers, for example, when asked their estimates of the proportion of health care dollars lost to outright fraud, placed that loss in a range of 3% to 5% (translation: annual loss of $30 billion to $50 billion of a $1 trillion expenditure)." The NHCAA concludes, "By whatever measure -- even the lowest estimates -- healthcare fraud is an enormous and intolerable drain on both our private and public health care system."
What impact does such fraud have on you? When a provider misrepresents his or her credentials and services, such fraud can jeopardize your health as well as your personal finances. Your healthcare coverage is also at risk. Some fraudulent doctors bill TRICARE with diagnoses that are more serious than the conditions actually are. By falsifying or exaggerating a diagnosis, a doctor can add to your medical record a condition you don't even have. And, of course, fraud means higher insurance premiums for everyone.

What can I do to prevent fraud?

Here are some tips to fight fraud:

Ask your doctor questions. Make sure you know and understand the procedures he or she performs.
Check your TRICARE Explanation of Benefits (TEOB) carefully. Is the date of service correct? Did you receive the services that were billed?
Know your cost-shares and copayments.

If you find a discrepancy, report it to the toll-free number of your Managed Care Support Contractor (MCSC) (see below). All calls can remain anonymous.

Health Net Federal Services 1-800-977-6761
Humana Military Healthcare Services 1-800-333-1620
TriWest Healthcare Alliance 1-888-584-9378
Sierra Military Health Services 1-888-999-5195 (This is a customer service number, but you may still report fraud anonymously. Or e-mail: prog-integrity@sierramilitary.com).

You can also write TMA if you suspect fraud or fax them at (303) 676-3981.

TRICARE Management Activity
Attn: Program Integrity
16401 East Centretech Parkway
Aurora, Colorado 80011-9043

Frequently Asked Questions about fraud

What is Upcoding?
Doctors who upcode purposely bill for services that cost more than the ones they actually performed. In doing so, they fraudulently receive a higher TRICARE payment.

What is a Participating Provider?
Providers who participate in TRICARE accept assignment -- that is, they agree to accept the TRICARE maximum allowable charge, including your cost-share and deductible, as payment in full. TRICARE-certified (authorized) providers can choose whether to accept assignment claim by claim. TRICARE network providers always accept assignment.

What is Balance Billing?
Balance billing occurs when a doctor or hospital bills you for the entire balance above the TRICARE maximum allowable charge. The Department of Defense Appropriations Act of 1993 limits the amount a non-participating provider may bill a TRICARE beneficiary. Those providers who do not accept assignment may bill no more than 115 percent of the TRICARE maximum allowable charge. This is the same percentage Medicare uses.

Fraud and the Internet

Healthcare fraud is becoming widespread on the Internet. Be sure to use only reputable Web sites, and do not enter personal information on a Web site unless you are sure it is a secure server.
Be aware that many Internet healthcare fraud cases involve Web sites that offer diagnostic tests for a fee. Check out such services carefully before you use them.
Remember that you should regard all offers you receive through e-mail just as cautiously as you do offers over the telephone, door-to-door or regular mail. Use common sense: an offer that sounds too good to be true probably is. Do not send any personal information, such as Social Security Numbers, credit card numbers, etc., over e-mail.

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How fraud affects you and what you can do to prevent it