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TRICARE Operations Manual 6010.62-M, April 2021
Program Integrity
Chapter 13
Section 1
General
Revision:  C-5001, June 23, 2021
1.0  CONTRACTOR'S PROGRAM INTEGRITY (PI) RESPONSIBILITY
1.1  The contractor shall establish and operate a dedicated TRICARE PI function.
1.1.1  The contractor shall ensure that medically necessary medical, pharmacy, and dental services are provided to only eligible beneficiaries by authorized providers or reimbursement made to eligible beneficiaries or providers under existing law, regulation and Defense Health Agency (DHA) instructions.
1.1.2  The contractor shall develop and implement a corporate strategy that is committed to health care fraud prevention and detection in the TRICARE program. The strategy shall include processes focused on health care fraud awareness, education, processes to identify health care fraud, correction, prevention, referral of health care fraud cases, prosecutorial support, and deterrence of health care fraud.
1.1.3  The contractor shall perform an annual fraud and abuse risk assessment to determine areas of vulnerability, high risk areas, specific fraud and abuse schemes, significance of risks, and mitigation measures within the scope of contract.
1.1.4  The contractor shall identify and implement cost-containment strategies and anti-fraud strategies to combat and prevent unnecessary spending that supports medically necessary and appropriate care in the TRICARE program.
1.1.5  The contractor shall submit a comprehensive PI plan that addresses the elements of paragraph 1.1. For plan submission requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.2  Use of Predictive Analytics and Anti-Fraud Software Requirements
1.2.1  The contractor shall perform analyses of non-institutional and institutional health care data associated with type, frequency, duration and extent of services with the intent of identifying patterns of fraudulent or abusive practices and behaviors by providers or beneficiaries on a prepayment (before claim is paid) and post-payment (after claim is paid) basis for the purposes of fraud prevention and detection.
1.2.2  The contractor shall obtain and utilize predictive analytics software. The anti-fraud software program(s) shall have predictive capabilities defined as the application of statistical models to assign probabilities and risk scores and detect fraudulent, abusive, and aberrant activities.
1.2.3  The contractor’s PI software components shall employ a variety of statistical modeling components and a wide range of analytic techniques and include but not be limited to predictive analytics and modeling, descriptive statistics, rules based analysis, predictive algorithms, trend analysis, and geographic clusters.
1.2.4  In order to be considered predictive, the software shall not be limited to only expert or rules based logic, and include more advanced analytical techniques such as artificial intelligence, machine learning, and regression techniques to flag providers for further evaluation.
1.2.5  The contractor’s PI software shall assign predictive risk scores to claims on a prepayment basis to evaluate the accrual of the new claims in aggregate with previously submitted claims in a pattern of fraud, abuse, or billing error. Relationships between providers shall be evaluated post-payment (flagged with flagged, flagged with non-flagged).
1.2.6  The contractor shall have trained staff to review and track providers flagged by the PI software on a daily basis.
1.2.7  The contractor shall use the results of this software to implement timely actions to prevent any further “suspect” claims and prevention of any further “suspect” claims. This paragraph is not applicable to the TRICARE Medicare Eligible Program (TMEP).
1.2.8  The contractor shall utilize predictive analytics software to utilize prepayment edits that specifically identify potential fraud and abuse.
1.2.9  The contractor’s software shall have reporting capability to produce comprehensive fraud detection reports and metrics to include reporting cost avoidance and cost savings.
1.2.10  The contractor shall augment and update software program accordingly to incorporate analytic approaches not mentioned, or, to leverage new statistical techniques or new applications of existing techniques.
1.2.11  The contractor shall report the results from the use of this software, both prepayment and post-payment results. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
1.3  Predictive Analytics And Modeling Metrics Report
1.3.1  The contractor shall report on a quarterly basis the key metrics covering the use and results of the predictive analytics and modeling software, as it was used prepayment (before claims are paid) and post-payment (after claims are paid) and report on actions taken from leads generated from use of software (e.g., prepayment, education). This requirement is specific to the predictive analytics and modeling software described in paragraph 1.2.
1.3.2  The contractor shall include the following statement at the bottom of each page for all reports generated as a results of this section or any other section in this chapter.
“The recipients of this report are hereby advised that it contains information that is Law Enforcement Sensitive”.
1.4  Anti-Fraud and Abuse Support
1.4.1  The contractor shall provide technical and professional consultation, support, and information to DHA PI to include but not limited to investigating and prosecuting support, submission, adjudication and reimbursement of claims for health care services, pharmacy or dental services.
•  Delivery of health care services in the 50 United States (US) and the District of Columbia and outside the 50 US and the District of Columbia.
•  Submission, adjudication and reimbursement of claims for health care services, pharmacy or dental services.
•  TRICARE operations and benefits.
•  Anti-fraud and Abuse activities.
1.4.2  The contractor shall:
1.4.2.1  Provide investigating and prosecuting support to include documents, reports, correspondence, audits, and other applicable data or items as requested.
1.4.2.2  Provide documents, reports, correspondence, claims data, and other applicable data or items in support of compliance monitoring, oversight activities, oversight monitoring, or other PI related issues.
1.4.2.3  Provide documents, reports, correspondence, claims data, and other applicable data or items in support of contractor actions.
1.4.2.4  Provide specific data and supporting documentation required during development and investigative process (i.e., initiated by contractor, law enforcement, Department of Justice (DOJ), or DHA PI).
1.4.3  At DHA PI’s request, identify and provide expert(s) or program witness(es) at Grand Jury hearings, criminal trials, civil hearings, depositions, and administrative hearings.
•  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.
1.4.4  Provide claims data and supporting documentation customary electronic format and media compliant with the Health Insurance Portability and Accountability Act (HIPAA).
1.4.4.1  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 and findings, or any other relevant information as requested (e.g., documents from other offices and units).
1.4.4.2  Have dedicated personnel and resources available to meet the timeliness requirement as directed by DHA PI for retrieval, transmission, and mailing of the information.
1.4.5  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)).
1.4.6  Comply 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.
1.4.7  The contractor shall develop, maintain and follow standard operating procedures related to requirements and activities within this chapter (e.g., desk procedures).
1.4.8  The contractor shall provide a copy, in electronic read-only format to DHA PI at the start of the contract with updates provided as changes occur. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
2.0  FRAUD AND ABUSE TRAINING AND EDUCATION
2.1  The contractor shall establish and maintain a formal training program for all contractor personnel in the prevention, detection, and reporting of potential fraud or abuse situations.
2.2  The contractor shall include fraud and abuse as a specific segment of its regular training programs and also include TRICARE specific information (refer to Chapter 1, Section 4).
2.3  The contractor shall provide training program material to DHA PI upon request.
2.4  PI Staff Education
2.4.1  The contractor shall ensure that all PI staff have adequate TRICARE and industry fraud and abuse training, education, and experience to perform TRICARE PI functions.
2.4.2  The contractor shall provide desk procedures to the staff which include methods for control of claims and encounters exhibiting unusual patterns of care, over or under utilization of services, or other practices which may indicate fraud or abuse.
2.4.3  The contractor shall include specific criteria for referral of cases to professional or supervisory review concerning issues with patterns of care, abnormal utilization practices, or suspect billing practices.
2.4.4  The contractor shall establish and maintain an ongoing anti-fraud and abuse education program addressed to beneficiaries, providers, and pharmacies. The education program shall provide information about identified fraudulent or abusive practices, and how individuals may identify and report such practices.
2.4.4.1  The contractor shall include information reminding providers seeking payment from the TRICARE program have a duty to familiarize themselves with, and to comply with program requirements.
2.4.4.2  The contractor shall accomplish this by including information in the provider quarterly newsletter, provider handbooks, email, World Wide Web (WWW), and other social media and by periodic notices on the electronic explanation of benefits and provider remittance advice.
2.4.4.3  The contractor shall provide copies of newsletters and notices to DHA PI upon request.
3.0  FRAUD AND ABUSE REPORTING MECHANISMS
3.1  The contractor shall have Fraud and Abuse reporting mechanisms available to beneficiaries, providers, and concerned parties to report suspected fraud and abuse.
3.2  The contractor shall have the ability to report fraud or abuse that are secure and HIPAA compliant by telephone, email, fax, secure online submission, and mail.
3.3  The contractor shall include anonymous and non-anonymous options (e.g., fraud hotline, email, fax, mail) for reporting also.
4.0  FEDERAL AGENCIES ROLES AND RESPONSIBILITIES (INFORMATIONAL)
4.1  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.
4.2  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 and state agencies.
4.3  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 also coordinates with DHA PI for actions pursued under the Program Fraud Civil Remedies Act (PFCRA), and initiating administrative measures. Settlements that affect the agency (e.g., civil settlement, a provider’s or pharmacy’s TRICARE status, sanctions) are coordinated with and approved by a DHA representative.
4.4  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.
4.5  Defense Criminal Investigative Service (DCIS) Of The DoDIG
DCIS is responsible for all fraud and 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 and 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).
4.6  Military Criminal Investigation Organizations (MCIOs)
The MCIOs include the United States Army Criminal Investigative Division (USACID), Naval Criminal Investigative Service (NCIS), United States (US) Air Force Office of Special Investigations (AFOSI), US 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.
4.7  Defense Contract Audit Agency (DCAA)
Upon request, the DCAA provides audit assistance to DHA, DCIS and MCIOs.
4.8  DOJ And US 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 US DOJ has jurisdiction for Federal criminal and civil action.
4.9  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.
5.0  EXTERNAL CONTRACTOR COORDINATION AND SUPPORT WITH DOJ, USAO, AND INVESTIGATIVE AGENCIES
5.1  The contractor shall not provide any information to external investigative agencies or any other entity without prior approval and coordination from DHA PI.
5.2  The contractor shall notify DHA PI when a contractor is contacted directly by any investigative or external agency (e.g., FBI, MCIOS, DCIS).
5.3  The contractor shall not release any documents (e.g., copies of document, audits) at the request of an individual or agency without direction DHA PI. This includes requests from all other entities, including anti-fraud associations.
5.4  It is DoD policy that all employees, contractors and subcontractors cooperate fully with investigative agencies of the US upon the direction of DHA PI.
5.5  The contractor shall provide all requests for claims histories, medical and other records, regulatory and manual provisions, correspondence, audits and other documentation (e.g., newsletters, claims, checks).
5.6  The contractor shall complete all requests for witnesses and technical support regardless of the time frames or dates of service identified in the request should this cross contractor jurisdiction or involve legacy contracts.
6.0  REPORTING
The contractor shall have reporting requirements that are compiled and submitted to DHA PI. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
6.1  Fraud And Abuse Summary Report
The Fraud and Abuse Summary Report shall be compiled and submitted to the DHA PI within 30 calendar days following the last calendar day of each calendar quarter.
6.2  PI Cost Avoidance And Recoupments
6.2.1  The contractor shall report to DHA PI the cost avoidance and recoupments achieved as a result of the activities, initiation, and involvement of the anti-fraud investigative unit and other units contributing to health care fraud detection, prevention, and deterrence.
6.2.2  The contractor shall provide information detailing:
6.2.2.1  Cost avoidance, recoveries, and recoupments; along with the cost associated with all PI activities.
6.2.2.2  Return on Investment (ROI): calculated by utilizing the DHA PI ROI tables provided on the quarterly report. Table requires utilizing aggregate labor, subcontracting, overhead administrative, technology, travel, training, and other miscellaneous costs associated with PI to be maintained by contractor.
6.2.2.3  Summarize all actions taken during reporting period to ensure timely action.
6.2.2.4  Information from the DMDC Claims Reprocessing Report which results in eligibility reviews, recoupments initiated, collected, or transferred to DHA.
6.2.2.5  A variance analysis for any reporting category with a 15% increase or decrease from the current quarterly report to the last quarterly report, to include any unusual activity even if it does not exceed the percentage. Provide a summary analysis to be included in the fourth quarter Fraud and Abuse Summary Report to reflect unusual activity that persists throughout all four quarters, and includes a year to year variance comparison for all periods of the contract. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
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