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.