Chapter No. 17 - If you Suspect Fraud or Abuse


If You Suspect Fraud and Abuse


Fraud happens when a person or organization deliberately deceives others to gain some sort of unauthorized benefit. Health care abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.


Fraud and abuse drive up health care costs. Review your bills and Explanation of Benefits (EOB) forms carefully for any -discrepancies. Notify your TRICARE contractor immediately using the toll-free telephone number that’s on the EOB.


If something doesn't seem right about your medical bills- perhaps the same item is billed twice, or you've been billed for services you never received, or


$ You think someone is providing inappropriate or unnecessary services, and billing for them, or


$ You think someone is providing lower-cost or used equipment while billing for higher-cost or new equipment, or


$ A supplier is completing a "certificate of medical necessity for a physician, or


$ A provider is Incorrectly reporting diagnoses, procedures, medications, or equipment to got a higher payment, or


$ Brand-name prescription medications are being billed for when generic drugs were provided, or


$ Individual psychotherapy is billed for when it was group counseling that was actually provided


Here's what to do:

1. Double-check the billings from your provider of care and the EOB you received from your TRICARE contractor. Be sure that the only services listed are ones you actually received.


2. If you can't resolve any problems you find by talking to the provider's billing office (some discrepancies might simply be the result of errors in billing), write to the program integrity unit of your regional TRICARE contractor. Explain what you think the problem is, and include copies of the EOB and any other relevant documents.


3. If you know, or have evidence of, another individual- whether it be a provider of care or a TRICARE-eligible person submitting fraudulent claims to TRICARE, write to the Managed Care Support Contractor (MCSC) in your area.


4. Although cost shares under TRICARE may vary, it's illegal for a provider to waive those cost shares. When a cost share is waived, it may keep you from seeking a much-needed second opinion. Here's an example: A woman is diagnosed with a terminal disease. Her physician waived her cost share (the portion of the medical bills she was supposed to pay), and the woman didn't seek a second opinion because she didn't want to pay a share of the second physician's charges. Months later, she found out that she wasn't terminally ill after all. A second opinion could have saved her months of unnecessary worry. You and TRICARE are partners in the payment of your medical expenses. Report to your regional TRICARE contractor any provider who waives your cost share.


Millions of tax dollars are lost to fraud and abuse of your health benefits programs each year. Your vigilance and alertness may be able to help bring perpetrators of health care fraud and abuse to justice.