Back to Top Skip to main content

Program Integrity Office

The Program Integrity Office at the Defense Health Agency (DHA) in Aurora, Colorado is the central coordinating agency for allegations of fraud and abuse within the TRICARE program.

What is fraud and abuse?

  • Fraud is when a person or organization deliberately deceives others to gain some sort of unauthorized benefit.
  • Abuse is when providers supply services or products that are medically unnecessary or that do not meet professional standards.

You're an important partner in the ongoing fight against fraud and abuse. If you suspect anything out of the ordinary, you should report it!

And remember, no one from TRICARE will ever contact you to recommend a particular product or medicine. If are ever contacted on the phone or via email, don't share any personal information and report the incident immediately.

Report Health Care Fraud Request Customer Service

Frequently Asked Questions

View questions and answers about health care fraud and abuse.

Q1:

What does the term "TRICARE" stand for?

A:

TRICARE is the health care program for service members (active duty, Guard/Reserve, retired) and their families around the world. TRICARE is a major part of the Military Health System. >>Learn More about TRICARE

Q2:

What's wrong with a provider waiving the beneficiary's cost-share?

A:

The beneficiary's cost-share is established by law. It protects both the beneficiary and the government. When a beneficiary is responsible for paying part of the cost of the care, we have found there is more attention paid to the accuracy of the Explanation of Benefits. If the charge is inaccurate, the beneficiary is likely to report the discrepancy. Many fraud cases are initiated as a result of such reportings. The cost-share also helps protect the beneficiary. When a beneficiary is responsible for paying 20-25 percent of a $10,000 procedure, he/she is likely to get a second medical opinion to ensure the services are medically necessary and appropriate. Providers cannot waive cost-shares. It is an obligation imposed by Congress for valid reasons. Waiver of the cost-share under the new fraud amendments is treated as a fraudulent act with separate dollar penalties.

Q3:

What is a mutually-exclusive edit?

A:

This is billing for two procedures that are either physically impossible to perform at the same time (such as an abdominal hysterectomy and a vaginal hysterectomy) or are really duplicative. In laboratory billings, a mutually-exclusive billing might be laboratory tests that are billed at the same time when it is necessary to wait for the results of the first before the second test is requested. In U.S. vs. Pickett, an ultrasound for a complete fetal and maternal evaluation was billed in addition to a fetal biophysical profile, basically the same procedure.

Q4:

What is meant by the term "upcoding"?

A:

Upcoding is the practice of billing the services at a higher level than what was actually provided to obtain reimbursement at a higher rate.

Q5:

Is upcoding fraudulent?

A:

Upcoding is considered fraudulent in that it is a misrepresentation of the services provided.

Q6:

What are some examples of upcoding?

A:

One example is billing for a 30 minute session of individual psychotherapy (90843) as if 45-50 minutes were provided (90844). Another is providing group psychotherapy but billing for it as if it were individual psychotherapy. Since a group psychotherapy session generally involves 4-10 patients, and individual psychotherapy reimburses at the rate of approximately $100 per hour, misrepresenting the services could give the provider a financial windfall of $400-$1000 per hour. Other types of upcoding exist, such as providing a unilateral mammography but billing for it as if it were a bilateral mammography.

Q7:

Can upcoding exist with office and hospital visits?

A:

Upcoding can exist in the selection of the Evaluation and Management codes (99000 series) which are used for office and hospital visits. In 1992, the Physicians Current Procedural Terminology (CPT) was revised to include specific time elements for each level of visit, specific clinical examples and a definition of what the patient's condition should be if a higher level code is selected. There are 5 levels of office visits, for both new patients and established patients. The level of office visit is determined by the number of diagnoses, the complexity of the case, the risk of complications or morbidity and the complexity of the decision making--straight-forward, low, moderate or high.

Q8:

Doesn't the new fraud legislation address upcoding?

A:

Yes. It provides for a $10,000 fine per incidence of upcoding, and with the clarification in the CPT as of 1992, clear-cut parameters exist as to what level is the appropriate one to bill.

Q9:

Is "unbundling" or "code gaming" considered fraudulent?

A:

"Unbundling," "fragmenting" or "code gaming" in order to manipulate the CPT codes as a means of increasing reimbursement is considered a misrepresentation of the services rendered. Such a practice is considered fraudulent and abusive. In US vs Pickett, a radiologist was convicted in a criminal trial for billing for a consultation in addition to the diagnostic imaging procedure which included performing the test and its interpretation. This is a form of unbundling or double billing.

You also may be interested in...

2016 Annual Fraud and Abuse Report

Report
4/28/2017

2016 Annual Fraud and Abuse Report capturing all the activities of the Program Integrity Office to thwart fraud, waste and abuse.

Recommended Content:

Program Integrity | Reporting Fraud or Abuse

Ten defendants charged in $100 Million TRICARE fraud scheme

Article
10/17/2016
Image of the TRICARE logo.

Special agents with the Federal Bureau of Investigation and the Defense Criminal Investigative Service arrested nine defendants this week in connection with their roles in a $100 million health care fraud conspiracy perpetrated against TRICARE

Recommended Content:

TRICARE Health Program | TRICARE Pharmacy Program | Program Integrity

25 arrested for fraud related to TRICARE and compound drugs

Article
7/18/2016
Image of the TRICARE logo.

Twenty-five people were arrested, accused of committing fraud against TRICARE

Recommended Content:

Program Integrity

2015 Annual Fraud and Abuse Report

Report
4/20/2016

2015 Annual Fraud and Abuse Report capturing all the activities of the Program Integrity Office to thwart fraud, waste and abuse.

Recommended Content:

Program Integrity | Reporting Fraud or Abuse

TRICARE beneficiaries being targeted by fraudulent mailing offer

Article
8/27/2015
Image of the TRICARE logo.

The Defense Health Agency, Office of Program Integrity (DHA-PI) has received a significant number of return envelopes from mailings by a bogus organization.

Recommended Content:

Program Integrity

TRICARE Beneficiaries Being Targeted by Call Centers and Others For Unsolicited Medical Prescriptions

Publication
4/10/2015

The Defense Health Agency, Office of Program Integrity (DHA-PI) has received a significant number of concerns from our TRICARE beneficiaries regarding unsolicited attempts by “Call Centers” to encourage them to provide personal identifying information and health information so that they can allegedly provide prescribed cream medications to the TRICARE ...

Recommended Content:

Program Integrity | Fraud Alerts

Anthem Blue Cross Blue Shield Data Breach

Publication
2/11/2015

Anthem Blue Cross Blue Shield states they were the target of a very sophisticated external cyber-attack. Anthem advises that once the attack was discovered, they immediately made every effort to close the security vulnerability.

Recommended Content:

Program Integrity | Fraud Alerts

Anti-Fraud Program and Audit Standardization Template

Publication
1/12/2015

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

Recommended Content:

Program Integrity

2014 Annual Fraud and Abuse Report

Report
12/31/2014

2014 Annual Fraud and Abuse Report capturing all the activities of the Program Integrity Office to thwart fraud, waste and abuse.

Recommended Content:

Program Integrity | Reporting Fraud or Abuse

DoDI 5505.12: Anti-Fraud Program at Military Treatment Facilities (MTFs)

Policy

This Instruction implements policy, assigns responsibilities, and prescribes procedures under References (a) and (b) for preventing, detecting, reporting, and evaluating suspected fraud by contracted civilian healthcare providers at all DoD MTFs. This Anti-Fraud Program is part of the DoD management control program prescribed by References (c), (d), and DoD Instruction 5010.40 (Reference (e)).

  • Identification #: DoD Instruction Number 5505.12
  • Date: 10/3/2013
  • Type: Instructions
  • Topics: Program Integrity

TRICARE Lottery Sweepstakes Scam

Publication
6/8/2012

TRICARE Program Integrity has become aware of a Lottery Sweepstakes Scam in which fraudulent checks bearing the TRICARE name are being utilized.

Recommended Content:

Fraud Alerts | Program Integrity

Unofficial TRICARE Websites

Publication
3/3/2010

Provides information related to privately hosted web sites that "appear" official, but ARE NOT operated by TRICARE or its contractors

Recommended Content:

Program Integrity | Fraud Alerts

Arrest of Earl B. Bradley

Publication
1/14/2010

Press release issued by the Attorney General for the State of Delaware concerning the arrest of Earl B. Bradley, M.D.

Recommended Content:

Program Integrity | Fraud Alerts

Express Scripts Reports New Threats Tied to Data Security Breach

Publication
11/11/2008

ESI, TRICARE's pharmacy contractor, reports Extortion Threat to Expose Personal Information of Members

Recommended Content:

Program Integrity | Fraud Alerts

TRICARE Patients Treated at Endoscopy Center of Southern Nevada

Publication
3/7/2008

The Southern Nevada Health District announced it is notifying approximately 40,000 patients of a local medical clinic about potential exposure to hepatitis C following an investigation of several acute cases of the illness.

Recommended Content:

Program Integrity | Fraud Alerts
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 10

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.