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TRICARE Urges Beneficiaries to Keep Alert for Signs of Fraud & Abuse

4/24/2014

According to the FBI, healthcare fraud costs the U.S. $80 billion per year. TRICARE is dedicated to protecting beneficiaries and their benefits, and actively works to prevent fraud, which can increase health care costs and the costs of coverage.

Healthcare fraud is when a person or organization deliberately deceives others to gain an unauthorized benefit. Healthcare abuse is when providers bill for services that were never received, supply services or products that are medically unnecessary or that do not meet professional standards.

In 2013, the Defense Health Agency (DHA), Program Integrity office received 96 “fraudline” referrals. “Many of these referrals involved beneficiaries who are no longer TRICARE eligible. It’s important that sponsors update their information and report any changes in eligibility to DEERS as soon as possible,” said Mr. Joseph O’Brien, with DHA Program Integrity. “All eligible beneficiaries must be registered in the Defense Enrollment Eligibility Reporting System (DEERS). Beneficiaries need to update DEERS whenever there is a life event or change in status. That is the key to minimizing fraud.”

Beneficiaries can help TRICARE reduce fraud and abuse by taking an active role in their healthcare.  Regularly review DEERS to ensure you and your family’s information is correct and up to date. If someone receives covered care and they are not eligible for TRICARE; that is considered fraud. This includes former spouses who get divorced from their TRICARE sponsor and do not meet the requirements for continued coverage.Reviewing your explanation of benefits (EOBs) is also a great way to watch for fraud. EOBs list healthcare services and supplies received, and you can check if you actually received the care and services listed on the EOB on the dates indicated.  If there are differences between what is on the EOB and the care you received, contact your regional contractor immediately. Find contact information for your regional contractor at www.TRICARE.mil/callus.

Many seemingly minor acts by providers may be fraud, such as failing to collect co-pays or cost shares, or attempting to collect more than is allowed from the beneficiary.  It is important to help TRICARE identify these events in order to save valuable benefit dollars. “If a beneficiary thinks fraud may have occurred, all of the TRICARE contractors have lines to report fraud,” said Mr. O’Brien. “Or, beneficiaries can contact the Program Integrity office and report suspected fraud and abuse directly.”

For more information on fraud and abuse visit, www.TRICARE.mil/fraud or you can submit a fraud report directly to the DHA Program Integrity Office.

Last Updated 7/9/2014