1.0 Contractor's
Program Integrity (PI) responsibility
1.1 The contractor shall incorporate
into its organizational management philosophy a published corporate
strategy that underlines commitment to health care fraud detection
and prevention. The strategy, developed and endorsed by corporate
management, shall include maintaining a focus on increased health
care fraud awareness, developing processes which identify fraud,
referring health care fraud cases, assisting in the prosecution
of the cases, and developing deterrents to health care fraud. Internal
procedures shall be in place for all offices to provide potential
fraud and abuse cases to the contractor’s PI function. The corresponding
Contract Data Requirements List (CDRL) DD Form 1423 provides details
on the contents and submission of the strategy and internal procedures
to include the published corporate strategy.
1.2 PI is a
contractor responsibility to ensure that necessary medical, pharmacy,
and dental services are provided only to eligible beneficiaries
by authorized providers or reimbursement made to eligible beneficiaries
or providers under existing law, Regulation and Defense Health Agency
(DHA) instructions. Further, the PI responsibility extends to applying
the expertise of the contractor staff to the evaluation of the quality
of care, and to ensure that payment is made for care which is in
keeping with generally accepted standards of medical, pharmacy,
or dental practice. In carrying out this function, the contractor
is required to apply all the standards and requirements addressed
in this and all other chapters of this manual. The contractor shall
have a dedicated PI function, solely for the Government line of
business, which shall perform the PI activities listed below and
shall respond to requests and direction from DHA Program Integrity
Office (PI).
1.3
Use
of Anti-Fraud Analytics
Contractor shall
perform analyses of professional and institutional health care data
associated with type, frequency, duration and extent of services,
to identify patterns of fraudulent or abusive practices by providers
and/or beneficiaries. Anti-fraud software program(s) must include
both expert (rules-based) and predictive analytics/modeling components.
Software must have fraud detection rules-based logic, fraud detection
analytics, predictive modeling, and statistical algorithm capabilities, along
with the ability to produce comprehensive fraud detection reports
and metrics. In order to be considered predictive, the software
must not be limited to only expert or rules based logic, and must include
more advanced analytical techniques such as artificial intelligence,
machine learning, and regression techniques. Predictive analytical/modeling
software must be used both pre-pay (before claims are paid) and
post-pay (after claims are paid) for the purposes of fraud detection.
The application must be on-line and accessible by the contractor’s
Program Integrity Unit fraud specialists. This paragraph is not
applicable to the TRICARE Dual Eligibility Fiscal Intermediary Contract
(TDEFIC).
1.4 Anti-Fraud
Support
1.4.1 Technical and professional consultation and
information shall be provided by the contractor (to include documentation)
as directed by DHA PI concerning:
• Delivery of health
care services in the Continental United States (CONUS) (or outside
of the Continental United States (OCONUS) when applicable).
• Submission, adjudication
and reimbursement of claims for health care services, pharmacy or
dental services.
• TRICARE
operations and benefits.
• Anti-fraud activities.
1.4.2 Investigating
and prosecuting support shall be provided by the contractor to include documents,
reports, correspondence, and other applicable data or items.
1.4.3 Documents,
reports, correspondence, and other applicable data or items shall
be provided by the contractor in support of compliance monitoring,
oversight activities, or other PI related issues.
1.4.4 Case specific
data required during development and investigative process shall
be provided by the contractor (i.e., initiated by contractor, law
enforcement, Department of Justice (DOJ), or DHA PI).
1.4.5 At DHA
PI’s request, the contractor must identify and provide expert(s)
or program witness(es) at Grand Jury hearings, criminal trials,
civil hearings/depositions and administrative hearings. An expert
witness is an individual having acquired a special skill or knowledge
through training or experience on a particular subject being discussed.
In addition, the types of expert witnesses that are covered by this
section are either individuals including PI specialists who worked
on the case or an expert in PI functions who could testify as to
the PI issues involved in the case. This also includes medical experts
if medical experts were used in the case development. A prosecutor
or defense attorney may request that a witness be declared an “expert
witness” based on their knowledge, such as someone from the policy
department or the contractor’s claims processing section. Travel
and per diem costs of witnesses subpoenaed by DOJ will be paid by
DOJ in accordance with Federal guidelines.
1.4.6 Claims data shall be provided
by the contractor in customary electronic format/media compliant
with the Health Insurance Portability and Accountability Act (HIPAA).
Other documentation or data to be provided may include, but is not
limited to, the original or copies of claims, explanations of benefits,
original or copies of checks (front and back), provider certification
forms, correspondence, medical records, audit records/findings,
or any other relevant information as requested (such as documents
from other offices/units). The contractor shall have dedicated personnel
and resources available to meet the timeliness requirement as directed
by DHA PI for retrieval, transmission, and/or mailing of the information.
1.4.7 The contractor
shall have the ability to electronically transfer all files, imaged
documents, data, and supporting documents, to include case referrals
in a manner that conforms with Government security protocols (e.g.,
protecting Protected Health Information (PHI)/Personally Identifiable Information
(PII)).
1.4.8 The contractor shall ensure compliance with
the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA)
Reorganization Act, Public Law 102-321 (July 10, 1992) and implementing regulations
including 42 CFR Part 2, when data requested includes services related
to substance abuse or mental health.
1.5 The contractor
shall develop and maintain standard operating procedures related
to requirements/activities within this chapter (e.g., desk procedures).
A copy, in electronic read-only format, shall be provided to DHA
PI at the start of the contract with updates provided as changes
occur. The corresponding CDRL, DD Form 1423, provides details of
the contents and submission of this report.
2.0 Roles
And Responsibilities Of Cooperating Components
2.1 DHA
The
Director, DHA, and designees administer the TRICARE program in accordance
with Title 10, Chapter 55, United States Code (USC), “Medical and
Dental Care,” 32 CFR 199, and other applicable laws, regulations,
directives and instructions.
2.2 DHA PI
DHA
PI is responsible for anti-fraud and abuse activities to protect
benefit dollars and safeguard eligible beneficiaries. DHA PI is
the central coordinating office for allegations of fraud and abuse
against the TRICARE program and is responsible for developing and
executing anti-fraud and abuse policies and procedures, provides
oversight of contractor PI activities, supports investigative activities, develops
cases for criminal prosecution and civil litigation, and initiates
administrative measures. DHA PI also exchanges information with
DOJ, law enforcement agencies, and federal/state agencies.
2.3 DHA Office
of General Counsel (OGC)
DHA OGC is responsible
for providing legal counsel and legal services to DHA. It is the
principal point of contact on all legal matters involving the DOJ
and its Federal Bureau of Investigation (FBI). This office serves
as DOJ’s primary contact point in civil litigation involving benefit
funds. DHA OGC is also responsible for actions pursued under the
Program Fraud Civil Remedies Act (PFCRA), overseeing contractor
PI activities, supporting investigations, developing cases for civil
prosecution and civil litigation, and initiating administrative
measures. Settlements that affect the agency (e.g., civil settlement,
a provider’s or pharmacy’s TRICARE status, sanctions, etc.) shall
be coordinated with and approved by a DHA representative.
2.4 Department
Of Defense Inspector General (DoDIG)
DoDIG
has the responsibility to conduct, supervise, monitor, and initiate
investigations relating to fraud within the DoD. This authority
specifically includes DHA, its employees, contractors and subcontractors.
This authority is not limited by the type of contract which has
been entered into by the Director, DHA. All contractor, managed
care, consultant, service, and other types of contracts are subject
to the audit, investigation and evaluation authority of the DoDIG.
2.5 Defense Criminal
Investigative Service (DCIS) Of The DoDIG
DCIS
is responsible for all fraud and/or abuse investigations involving
the Secretary of Defense, the Office of the Joint Chiefs of Staff
(JCOS), the Defense Agencies (including the DHA), and any other fraud
investigation deemed appropriate by the DoDIG or designated representative.
DCIS has primary investigative jurisdiction for cases concerning
alleged TRICARE fraud/abuse. This includes cases that may involve
the use of facilities by medical providers on military installations
and managed care cases (to include network providers or network
pharmacies).
2.6 Military Criminal Investigation
Organizations (MCIOs)
The MCIOs include the
United States Army Criminal Investigative Division (USACID), Naval Criminal
Investigative Service (NCIS), United States (U.S.) Air Force Office
of Special Investigations (AFOSI), U.S. Coast Guard (USCG) Investigations
and Health and Human Services (HHS) Inspector General’s Office (for
the United States Public Health Service (USPHS)). The MCIOs have
jurisdiction to investigate cases concerning alleged fraud by active
duty military Service members and their family members who have
received health care services, and retired services members and
their family members.
2.7 Defense Contract Audit Agency
(DCAA)
Upon request, the DCAA provides audit
assistance to DHA DCIS and MCIOs.
2.8 DOJ And U.S. Attorneys’ Offices
(USAO)
The DOJ, acting through its Civil
and Criminal Divisions, and the USAO have responsibility for litigation
and prosecution of cases involving violation of the civil and criminal
laws of the U.S. DOJ has jurisdiction for federal criminal and civil
action.
2.9 FBI
The FBI is the principal investigative arm
of the DOJ. It has primary responsibility for investigating federal
employee bribery and conflict of interest cases and other violations
of Federal law except those that have been assigned by law or otherwise
to another Federal agency. In addition, it has the authority to
investigate Federal agencies, Federal contractors, and Federal program
fraud such as the submission of fraudulent TRICARE claims.
3.0 Coordination
And Support: Other Contractors And External Agencies
3.1 Contractor Coordination With
Other TRICARE Contractors
3.1.1 Contractors shall coordinate
their activities and case data with other TRICARE contractors since
potential fraud or abuse involving a provider, pharmacy, or beneficiary
could have a direct effect on payments made by another contractor.
This shall occur during the initial stages of case development.
The contractor PI unit who initiates the case shall contact the
other contractor PI unit for exposure. The initiating contractor
PI unit shall provide the other contractor PI unit with the fraud/abuse
scheme, name of provider (s) to include practice name, Tax Identification
Numbers (TINs), National Provider Identifier (NPI), or National
Council of Prescription Drug Program (NCPDP) provider Identification
and date range so research may be conducted. DHA PI shall be informed
in the case report of these contacts and findings if suspected practice
is a pattern among national or regional chains. Findings of potential
fraud or abuse by another contractor shall be reported to DHA PI
by the contractor who initiated the investigation.
3.1.2 In any
situation which could lead to duplicate investigative efforts, the
contractors involved must notify DHA PI for the proper coordination.
Joint case referrals shall be submitted by the contractor that initiated
the case first. Each contractor with exposure will conduct an independent
audit; however, all findings shall be submitted by the initiating
contractor PI unit.
3.1.3 Those issues that cannot be
resolved at the operational level between the contractors shall be
elevated to DHA PI for resolution.
3.2 Contractor Coordination And
Support With DOJ, USAO, And Investigative Agencies
3.2.1 Requests for health care fraud
and abuse information by DOJ and DCIS must be referred to DHA PI.
Contractor contact by any investigative agency, e.g., FBI, MCIOs,
etc., shall also be reported immediately to DHA PI. The contractor
may not release any documents or copies of documents, conduct audits,
etc., at the request of any individual or agency without direction
from DHA PI. (This includes requests from all other entities, including
anti-fraud associations). If the contractor responds directly to
a request for documentation from an investigative agency or other
entity, the costs of responding shall not be charged to the contract.
3.2.2 It is DoD
policy that all employees, contractors and subcontractors shall
cooperate fully with investigative agencies of the U.S. upon the
direction of DHA PI. All requests for claims histories, medical
and other records, regulatory/manual provisions, correspondence,
audits and other documentation (e.g., newsletters, claims, checks,
etc.) shall be provided by the contractor. Requests for witnesses
and technical support will be completed by the contractor regardless
of the time frames or dates of service identified in the request
should this cross contractor jurisdiction or involve legacy contracts.