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 you 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.

You also may be interested in...

Dr. Peter W. Jannace Charged

Publication
10/3/2000

Dr. Peter W. Jannace charged with mail fraud, health care fraud and submitting false claims.

Recommended Content:

Program Integrity | Fraud Alerts

Samiha Mitwally Pleads Guilty

Publication
9/19/2000

Mitwally pled guilty to devising a scheme, starting in 1997, where her companies would receive small dollar purchase order contracts from various DoD medical centers and hospitals.

Recommended Content:

Program Integrity | Fraud Alerts

Lannes Neil Johnson Sentenced

Publication
9/15/2000

Lannes Neil Johnson was sentenced to three years probation and a special assessment fee of $50 for conspiring to submit false claims.

Recommended Content:

Program Integrity | Fraud Alerts

New England Health Associates Settles

Publication
9/13/2000

New England Health Associates, Incorporated (NEHA) agreed to pay $493,465 to settle allegations under the False Claims Act that NEHA submitted, or caused to be submitted, false claims to Medicare, Medicaid and TRICARE.

Recommended Content:

Program Integrity | Fraud Alerts

Settlement Reached with Douglas Colkitt

Publication
9/8/2000

The investigation of Equimed, Inc. was for alleged healthcare fraud in the radiation oncology field.

Recommended Content:

Fraud Alerts | Program Integrity

Stephen Scott McLemore Sentenced

Publication
9/6/2000

McLemore pled guilty to onecount of filing false claims to the U.S. Government on February 14, 2000.

Recommended Content:

Program Integrity | Fraud Alerts

Joel L Lang Pleads Guilty to Mail Fraud

Publication
8/30/2000

Dr. Joel J. Lang, Podiatrist,pled guilty to one of count mail fraud relating to the submission of fraudulent health care billings.

Recommended Content:

Program Integrity | Fraud Alerts

John A. Campa III Indicted

Publication
8/22/2000

Campa indicted for allegedly making false statements in connection wit ha health care matter, health care fraud and mail fraud.

Recommended Content:

Program Integrity | Fraud Alerts

Arthritis Pain Center Sentenced

Publication
8/18/2000

Company sentenced to 2 years probation, fined $10,000, ordered to pay a $400 special assessment, and ordered to make restitution to Medicare, TRICARE, and private insurance companies in the amount of $50,000.

Recommended Content:

Program Integrity | Fraud Alerts

Samir Najjar Pleads Guilty

Publication
8/10/2000

Dr. Samir Najjar, M.D., pled guilty to a one count of making a false statement to the U.S. Government in connection with TRICARE.

Recommended Content:

Program Integrity | Fraud Alerts

Frances Carr Casper Sentenced

Publication
8/8/2000

Casper previously pled guilty on May 17, 2000, to a criminal information charging her with conspiracy to commit health care fraud.

Recommended Content:

Program Integrity | Fraud Alerts

Nasser Ordoubadi Pleas Guilty

Publication
8/4/2000

Nasser Ordoubadi M.D. entered a guilty plea to two counts of conspiracy to commit health care fraud and mail fraud.

Recommended Content:

Program Integrity | Fraud Alerts

Dialysis Holdings Laboratory Services, Inc. Enters Settlement Agreement

Publication
8/2/2000

The agreement was the result of an investigation of allegations that DHLSI defrauded TRICARE, Medicare and Medicaid by billing for laboratory services that were medically unnecessary, double billing Medicare Part B for tests that were included in the composite rate paid by Medicare Part A.

Recommended Content:

Program Integrity | Fraud Alerts

Gambro Healthcare Laboratory Services Enters Settlement Agreement

Publication
8/2/2000

Agreement was the result of an investigation of allegations that Gambro defrauded TRICARE, Medicare and Medicaid by billing for laboratory services that were medically unnecessary, double billing and unbundling.

Recommended Content:

Program Integrity | Fraud Alerts

Doctor Ira Liss Sentenced

Publication
7/28/2000

Dr. Liss was sentenced to 15 months incarceration, 2 years supervised release, $29,000 in restitution, fined $5,000 and ordered to pay a special assessment fee of $600.

Recommended Content:

Program Integrity | Fraud Alerts
<< < ... 6 7 8 9 10 > >> 
Showing results 106 - 120 Page 8 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.