Have you heard the term “health care fraud and abuse” and wondered what it means? Health care fraud and abuse occurs when a person or organization deliberately lies or misleads to gain a benefit they shouldn’t receive. It also happens when health care providers bill for services and products that you don’t need or that don’t meet medical standards. Fraud and abuse also affect TRICARE.
“Most TRICARE providers are honest and ethical, but unfortunately, some aren’t,” said Jennifer Dietz, director of the Health Care Fraud Division for the Defense Health Agency Office of the Inspector General. “Each year, fraud and abuse result in the loss of millions of taxpayer dollars that were meant to support health care for our service members and other TRICARE beneficiaries.”
You can play an important role in identifying and reporting practices that don’t seem appropriate. Keep reading to learn how to recognize, report, and prevent fraud and abuse.
How to recognize fraud and abuse
Providers, beneficiaries, and other organizations can commit health care fraud and abuse in many ways.
Examples of fraud include:
- Submitting claims for services not provided or used
- Falsifying claims or medical records
- Misrepresenting dates, frequency, duration, or description of services rendered
- Billing for services at a higher level than provided or necessary
- Falsifying eligibility
- Failing to disclose coverage under other health insurance
Examples of abuse include:
- A pattern of waiving cost-shares or deductibles
- Failure to maintain adequate medical or financial records
- A pattern of claims for services not medically necessary
- Refusal to furnish or allow access to medical records
- Improper billing practices
How to report suspected fraud and abuse
Fraud and abuse can target your TRICARE medical, pharmacy, and dental coverage. If you think someone is committing fraud or abuse related to your TRICARE benefits, you should report it.
There are several ways to make a report:
When reporting, provide as much information as possible. This may include names, dates, and details of the situation. Investigations are confidential, and you can choose to remain anonymous.
How you can help prevent fraud and abuse
There are ways to prevent health care fraud and abuse before it happens to you. The Federal Bureau of Investigation recommends three simple tips for preventing health care fraud and abuse:
- Protect your health plan information. Treat your health plan information like a credit card. Don’t give it to anyone to use and be cautious when giving it out at the doctor’s or pharmacy.
- Beware of “free” services. Anyone who asks you to share your health plan information in exchange for “free” services may be trying to scam you. The service probably isn’t free, and it could be fraudulently charged to TRICARE.
- Check your explanation of benefits (EOB) regularly. Double check that the dates, locations, and services you were billed for are the same as the care you received.
Keep track of every bill you receive to ensure you aren’t being billed for the same service more than once. You can also compare your bill to the EOB you receive from your TRICARE contractor. Because some billing errors are mistakes, contact your provider’s billing office if you find a discrepancy. If the provider can’t resolve the discrepancy, contact the appropriate TRICARE contractor.
Also, be aware of common health care scams that could affect you. Remember, TRICARE will never call or email to ask you for your Social Security number or recommend a specific treatment or drug. If someone contacts you by phone or email asking for personal or health information, don’t provide this information. Instead, report it to the appropriate TRICARE contractor right away.
For more information on how to prevent TRICARE fraud and abuse, go to Reporting Fraud and Abuse.