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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.

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Jay Ronnie Roffman Enters Plea Agreement

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10/4/2001

Roffman was indicted on 40 counts of mail fraud and 1 conspiracy charge by a Federal grand jury. As part of the plea agreement, Roffman pled guilty to onecount of mail fraud.

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Eileen B. Aird Sentenced

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Aird pled guilty on June 11, 2001 to misprision of a felony with regard to double billing the Medicare program for approximately $4.9 million.

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David Jett Sentenced

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Jett had previously pled guilty to a 1-count criminal information charging conspiracy in connection with a violation of the prescription drug marketing act (unlicensed wholesaling of prescription drugs).

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Grace Hosptial Settles Qui Tam Lawsuit

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Grace Hospital fraudulently classified inpatients as observation outpatients and billed for respiratory therapy services that were not provided.

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John A. Campa III Sentenced

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Campa sentenced to 24 months incarceration followed by a period of supervised release of 3 years, $219,650.36 restitution, and a special assessment of $5,550. Campa was ordered to perform 150 hours of community service.

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Caritas Medical Group Paid Fine

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Samuel E. Wahba Found Guilty

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Suman Dewan M.D. Pled Guilty

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This plea is a result of an investigation of allegations Dewan submitted false claims by billing TRICARE, Medicare and the Federal Employee Health Benefits Plan for skin graft procedures.

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HealthWise Medical Rehabilitation Centers Found Guilty

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Concessi and Healthwise were indicted on charges relating to the submission of numerous fraudulent health care claims for payment to TRICARE and the TRIGON Insurance Company.

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Dr. Joseph S. Olstein Pleads Guilty

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Dr. Joseph S. Olstein entered a guilty plea to charges he conspired to defraud Federal health care programs by violating the Prescription Drug Marketing Act.

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Dr Lucia Pinon Quintana Charged with Income Tax Evasion

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Dr. Quintana received monthly kickback payments from two competing mobile ultrasound diagnostic companies.

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Richard Bennett Powell and his wife, Joanne Taylor Powell pled guilty to charges of healthcare fraud

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Romualdo N. Garcia Sentenced

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

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