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TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Overseas Program (TOP)
Chapter 24
Section 14
Program Integrity
Revision:  C-26, May 30, 2018
1.0  General
All TRICARE requirements regarding program integrity shall apply to the TRICARE Overseas Program (TOP) unless specifically changed, waived, or superseded by this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (U.S.) and the District of Columbia (hereinafter referred to as the “TOP contract”). See Chapter 13 for additional instructions.
1.1  In addition to the requirements outlined in Chapter 13, the Government may implement additional requirements as necessary to prevent or detect fraud in overseas locations.
1.1.1  The contractor shall perform 12 Statistically Valid Random Sample (SVRS) audits per option period to examine and verify the accuracy of claims. See Chapter 13, Section 3 for additional information regarding case development audits. The contractor shall ensure that an SVRS is done in accordance with Chapter 13, Section 3, paragraph 3.2.2. Those audits meeting the dollar threshold for case referrals shall be handled in accordance with Chapter 13 provisions.
1.1.2  For those audits not meeting the dollar threshold for case referrals, recoupment action shall be taken on actual damages determined as a result of errors identified in an SVRS. See Chapter 13 for further guidance.
Note:  TRICARE guidance regarding anti-fraud programs at Military Treatment Facilities (MTFs) is contained in Department of Defense Instruction (DoDI) 5505.12 (October 19, 2006). This instruction is located at: http://www.dtic.mil/whs/directives/corres/pdf/550512p.pdf.
1.2  The TRICARE Area Office (TAO) Directors shall report possible fraudulent or abuse practices by a TOP beneficiary/purchased care sector provider to the TOP contractor, the appropriate Defense Health Agency (DHA) Contracting Officer’s Representative (COR), and the DHA Program Integrity Office (PI), including requests for the contractor to flag or watch providers suspected of fraud and abuse.
2.0  Contractor Responsibilities
2.1  The TOP contractor shall notify the DHA PI in writing of any new or ongoing fraud and abuse issues.
2.2  In cases involving check fraud, the TOP contractor is not required to reissue checks until the investigation is finalized, fraud has been determined, and the contractor has received the money back from the investigating bank.
2.3  Upon direction from DHA, the contractor shall discontinue payments to Third Party Administrators (TPAs) in countries or specific agencies where significant fraud is occurring on a regular basis.
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