Briefing: Anti-Fraud Campaign Date: 21 March 2007 Time: 0900 - 0950

1. Briefing: Anti-Fraud Campaign Date: 21 March 2007 Time: 0900 - 0950

2. Overview • Overview: • Mission of Program Integrity • Major Roles & Responsibilities • Effective Partnering • New DoD Instruction for MTF Anti-Fraud Program • Fraud/Abuse Scenarios • Referral Process • Impact of Anti-Fraud activities

3. Mission/Vision Statement • Our Mission • Responsible for anti-fraud activities worldwide for DHP • Execute policies/procedures regarding prevention, detection, investigation, and control of fraud, waste, and abuse in the administration of TRICARE • Our Vision • Ensure that DHP and its contractors have an effective fraud control program in place

4. Strategy • Pursuing a strategy intended to deter fraud, waste, and abuse: • Prevention • Detection • Coordination • Enforcement COST of fraud: $50-100 billion a year!

5. Roles/Responsibilities • Roles/Responsibilities – Major Players: • TMA-Program Integrity Office • Contractor & Sub-contractor staff • Defense Criminal Investigative Service • Department of Justice

6. Roles/Responsibilities • Roles/Responsibilities – Major Players: • Providers of Care • Beneficiary Community • Beneficiary Counseling & Asst. Coordinator • Defense Health Program Personnel • TRICARE Regional Offices

7. MTF Policy Anti-Fraud Program at Military Treatment Facilities (MTFs), DoD Instruction 5505.12, October 18, 2006: • Purpose: • Implements policy, assigns responsibilities, and prescribes procedures for preventing, detecting, evaluating and reporting suspected fraud by contracted civilian providers at all MTFs • Policy: • Establish and implementing anti-fraud programs designed to ensure appropriate expenditure of financial resources in the delivery of healthcare to entitled beneficiaries –Continued–

8. MTF Policy Anti-Fraud Program at MTFs • Procedures: • Document roles and responsibilities addressing civilian contracts for civilian providers to deliver healthcare at DHP funded MTFs • Use of “Anti-fraud & audit standardization program template” • Implement anti-fraud training protocol for personnel • Utilization of existing patient encounter databases • Oversight of contracted providers and local civilian entities • Provide TMA PI case referral information with supporting documentation

9. Definitions • What is fraud? • Fraud is any intentional deception or misrepresentation that an individual or entity does that could result in an unauthorized TRICARE benefit or payment • What is abuse? • Abuse is any practice by providers, physicians, or suppliers that is inconsistent with accepted medical or business practice

10. Who Commits Fraud? • Who commits fraud? • Majority of fraud is committed by dishonest physicians, billing agencies, and other health care professionals • Examples: Physicians; laboratories; hospitals; psychiatrists; ambulance companies; & clinics • Lesser percentages attributed to patient fraud/abuse • Contractor or employee fraud

11. Types of Fraud • Types of Fraud Seen within the DHP

12. Fraud/Abuse Scenarios Common Fraud/Abuse Scenarios • Billing for services not rendered • Misrepresentation (ex: provider, services, supplies and/or beneficiary) • Billing for more services in a 24-hour period than is possible to perform • Upcoding services/unbundling services • Patient harm/abuse (including identity theft) • Billing non-covered services disguised as covered services

13. Fraud/Abuse Scenarios More common scenarios • Ping-Ponging patients between doctors/clinics • Flagrant and persistent over-utilization of services or billing unnecessary services • Waiving the deductible or cost-share and/or offering a financial inducement or free services • Padding health care bill to include administrative charges or network billing/claims preparation • Unlawful supplemental insurance plans

14. $ $ $ Fraud/Abuse Scenarios More common scenarios • Pharmaceutical fraud • Durable medical equipment • Surgical/hospital fraud • Dental fraud • Psychiatric services • Ambulance services

15. Outcomes • Potential Outcomes • Criminal Conviction • Civil Settlement • Administrative Action Examples: Educate, recoup overpayments • Termination • Sanction Action

16. Your Role • Referral process – Your role in fighting fraud • Commitment to health care fraud detection and prevention • Timely identification of potential fraud/abuse issues • Focus on increased health care fraud awareness • Developing deterrents to health care fraud/abuse • Knowledgeable about what constitutes health care fraud • Reporting potential cases to TMA–Aurora PI Office

17. Referral Process • Referral Process • #1 Rule: KEEP IT SIMPLE! • Who • What • Where • When • How • Why • Purpose is to quickly educate TMA PI staff, DCIS agent, and the prosecutor who will not be familiar with your case referral

18. Referral Process • Referral Process • Case referral letter requesting TMA-PI review • Backup “Fact Sheet” detailing: • Provider Identification • Suspected aberrant, abusive or fraudulent billings • How the case was identified • Evidence & background • Commanding officer coordination • Point of contact • Two copies please!

19. POC Information • POC for Fraud Referrals • TRICARE Management Activity Program Integrity Office 16401 East Centretech Parkway Aurora, CO 80011 Phone: (303) 676-3824 Fax: (303) 676-3981

20. Anti-Fraud Efforts • Why anti-fraud efforts are so important • Contractual Requirement – Present performance impacts future awards! • MTFs – Ensures appropriate expenditure of financial resources in healthcare delivery • Good business practice • Ensures medically necessary and appropriate care for our beneficiaries by ferreting out fraud • Program savings!! Reflects success of staff efforts!

21. Partnering • Effective Partnering • Identifying suitable partners • Securing involvement • Working together for common goal • Mobilizing & accessing resources • Sharing of information/networking

22. Partnering • Effective Partnering – Results • Important “vehicle” for addressing issues impacting everyone • Achieves higher value in “deliverables” and bottom-line savings to program • United fight against health care fraud

23. Affiliations • Affiliations • NHCAA • DOJ Health Care Fraud Working Group • DOJ Task Force on Pharmaceutical Fraud • Quality Health Care Forum • DCIS • HHS-IG • PDTS • CHAMPVA/VA • DCAA • OPM-OIG

24. Publications • Publications • Annual Operations Report • Monthly Spotlight • Fraud Newsletter for Law Enforcement/Contractor Anti-Fraud Units • Fraud Alerts, as necessary • Fraud Facts & Tidbits – as needed to enhance fraud awareness • TRICARE Fraud web page – www.tricare.osd.mil/fraud

25. Resources • Treasure Chest of Investigative Resources • TRICARE National Database • Access to CMS database • Access to NHCAA “Siris” database • Artificial Intelligence software

26. Impact • Impact of Anti-Fraud activities: • Fraud Judgments (Civil Settlements & Criminal Restitution) = benefit dollars returned to the program! • Fiscal stewardship = program savings • Deterrent effect! • Program improvements • Implementing/tightening administrative controls • Meets MHS goal of sustaining health benefit