The DHA Program Integrity Division (PID) is responsible for healthcare anti-fraud activities to protect benefit dollars and safeguard beneficiaries. This includes both the purchased care and direct care settings. DHA PID develops and executes anti-fraud and abuse policies and procedures, provides oversight of contractor program integrity activities, supports and coordinates investigative activities, develops cases for criminal prosecution and civil litigation, and initiates administrative measures.
DHA PID is part of the DHA Special Staff and reports directly to the DHA Chief of Staff. This reporting structure facilitates DHA PID’s anti-fraud activities. Because of the nature and scope of the work performed by DHA PID, its reporting line is separate and distinct organizationally from the day-to-day operational activities of other departments to avoid the appearance or potential of undue influence or conflict of interest.
Recognizing the importance of sharing information with the investigative community, DHA PID(often a presenter) regularly attends task force meetings, information sharing meetings, and healthcare anti-fraud…
Through a Memorandum of Agreement, DHA PID refers its fraud cases to the Defense Criminal Investigative Service (DCIS). DHA PID also coordinates investigative activities with Military Criminal Investigative Offices (MCIOs), as well as other federal, state, and local agencies. DHA PID provides technical assistance, subject matter expertise, and support to U.S. Attorney Offices (USAOs), law enforcement agencies, and others in developing cases for criminal prosecution, civil litigation and/or settlements. This includes providing witness testimony related to the TRICARE program and its range of benefits. This support is continuous and ongoing throughout the investigative, settlement, and/or prosecutorial phases of cases…
This section details the results of cost avoidance activities.
3.1 Prepayment Duplicate Denials
TRICARE’s Managed Care Support Contractors (MCSC) along with International SOS (ISOS), Wisconsin Physician Service (WPS), Express Scripts Incorporated (ESI), and United Concordia Dental, Inc. utilize claim software that screens and audits claim coding. One significant area reviewed is that of duplicate claims submissions. When duplicate claims submissions are identified the duplicate claim is denied. For calendar year 2019 prepayment duplicate denials reported by the contractors to Program Integrity amounted to $ 594,743,871.
3.2 Rebundling/Mutually Exclusive Edits
TRICARE’s MCSC’s, ISOS, and WPS are required to use prepayment claims processing software that utilizes rebundling and mutually exclusive edits. The rebundling edits are designed to detect and correct the billing practice known as unbundling, fragmenting, or code gaming. Unbundling involves the separate reporting of the component parts of a procedure instead of reporting a single code, which includes the entire comprehensive procedure. This practice is improper and is a misrepresentation of the services rendered. Providers are cautioned that such a practice can be considered fraudulent and abusive. For calendar year 2019, the prepayment claims processing software in use by the MCSCs accounted for $104,328,9771 in cost avoidance for TRICARE.
3.3 Prepayment Review
Prepayment review prevents payment for questionable billing practices or fraudulent services. Providers/beneficiaries with atypical billing patterns may be placed on prepayment review. Once on prepayment review their claims and supporting documentation are subjected to prepayment screening to verify that the claims are free of billing problems. The results of a review may result in a reduction of what was claimed or a complete denial of the claim. The following chart shows by contractor, cost avoided as a result of prepayment review activities…
The PDF download is available here.
Source: 2019 Annual Fraud and Abuse Report – April 17, 2020. Health.mil.
