1.1 Controls
for the Prevention And Detection Of Fraudulent Or Abusive Practices
The
contractor shall establish procedures and utilize controls for the
prevention and detection of fraudulent or abusive patterns and trends
in billings by providers, pharmacies, entities, and beneficiaries
on a pre- and postpayment basis. Controls shall include the following
(and be made available to the Defense Health Agency (DHA) Program
Integrity Office (PI)):
• Eligibility
verifications for beneficiaries and providers/pharmacies.
• Coordination
of benefits.
• Prepayment edits (e.g., applied
to program exclusions and limitations).
• Utilization
of discretionary or coordinated placement of providers/beneficiaries
on prepayment review.
• Postpayment
utilization review to detect fraud and/or abuse by either beneficiaries, pharmacies,
or providers and to establish dollar loss to the Government.
• Application
of security measures to protect against embezzlement or other dishonest acts
by employees.
• Incorporate anti-fraud attestation
language whenever/wherever practical (e.g., claim forms, network
agreements, electronic claims submission agreements).
• Utilization
of Fraudlines/Hotlines.
• Prepayment
duplicate screening.
• Postpayment
duplicate screening.
• Verification
of provider status (e.g., credentials, licensure) to include appropriate termination
action when findings/recommendations of boards, etc. results in
loss or suspension of licensure or certification.
• Program
Integrity (PI) targeted measures (e.g., prepay anti-fraud review;
use of post payment fraud detection software; routine anti-fraud
data mining; investigative anti-fraud auditing; select provider/beneficiary
education).
• Specific to pharmacy, controls
include comparing reversal rates; excessive partial fill submissions;
high use patients; review of outliers; codes with medication therapy
for high ingredient costs; claims with high average ingredient cost;
review of brand/generic fill rates; top pharmacies per generic code
rate; controlled substance prescription rates; and ability to conduct
on-site audits of pharmacies who meet these indicators and ability
to review/perform on-site of top one percent of providers who meet
these indicators.