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.