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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 Self Disclosure Program

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 U.S. 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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Jack Campo Sentenced

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6/12/2001

Campo sentenced to 37 months in prison, ordered to pay $923,100 restitution, and a special assessment fee of $800.

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Eileen B Aird Pleasds Guilty

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6/11/2001

Eileen B. Aird pled guilty to 1-count criminal superseding information charging her with misprision of a felony with regard to double billing the Medicare program for approximately $4.9 million.

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James Paul Kalhorn, D.D.S. Sentenced in Federal District Court

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6/1/2001

James Paul Kalhorn, D.D.S. was sentenced in Federal District Court to 2 years probation and ordered to pay $25,000 in restitution and a $5,000 fine. On February 15,2001, Kalhorn pled guilty to a one count information charging him with making or causing to be made a false statement or representation involving a Federal health care program.

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Markoll Pleads Guilty

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5/18/2001

Richard Markoll, Ernestine Binder Markoll and Magnetic Therapy Incorporated (Magnetic Therapy) pled guilty to conspiracy and mail fraud charges.

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Healthsouth Corporation Entered into a Settlement Agreement

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Healthsouth Corporation entered into a Settlement Agreement to pay the United States $7.9 million and agree to comply with a Corporate Integrity Agreement between it and the U.S. Health and Human Services, Office of the Inspector General.

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Carol Doggette Sentenced

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5/18/2001

Sentencing is the result of an earlier guilty plea by Doggette for submitting false claims tothe U.S. Government.

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Lawrence Edwin Crumbliss Sentenced

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Crumbliss and three codefendants were charged with converting more than $300,000 for their personal use.

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Settlement Reached with Catholic Health Care West and Mercy Health Care

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Settlement was the result of an investigation that disclosed CHW and Mercy allegedly defrauded the Medicare and TRICARE programs by filing false cost reports.

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Suman Dewan M.D. Indicted

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Samiha Mitwally Sentenced

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Samiha Mitwally was sentenced to 15 months in prison, with 3 years supervised release,and ordered to pay restitution of $61,704, and a $2,400 special assessment.

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24-count Indictment Returned Against HealthWise Medical Rehabilitation Centers

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The Office of the Inspector General (OIG), Department of Defense (DoD) returned a 24-count indictment against HealthWise Medical Rehabilitation Centers (HealthWise), Chesapeake and Virginia Beach, VA, and Michael J. Concessi,Doctor of Chiropractic (DC) and owner/operator of HealthWise. Each of the defendants was charged with one count of health ...

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Dr Samir Najjar Sentenced

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Dr. Samir Najjar, M.D. was sentenced to serve 36 months in confinement, 36 months of supervised release, pay $5 million in restitution, and a $50 specialassessment fee.

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Dr. Whitney B. Freeman Sentenced

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4/24/2001

Freeman knowingly and willfully executed and attempted to execute a scheme to defraud TRICARE and 17 other health care benefit programs by submitting approximately 123 claims for services Freeman had not performed.

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Community Clinical Laboratory Leaders Sentenced

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4/20/2001

President and general manager sentenced for conspiring to defraud the TRICARE and Medicare health care programs by making kickback payments to physicians for patient referrals.

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Dr. Bipin Patel Sentenced

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Patel previously pled guilty for conspiring to defraud the TRICARE and Medicare health care programs by taking kickback payments from Community Clinical Laboratories

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

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