3.5 Case
Summary
The contractor
shall submit a Case Summary when referring cases of potential fraud
or abuse that describes includes the following but not limited to:
3.5.1 Allegations
citing all the applicable TRICARE regulatory provisions that have
been violated in regards to each allegation.
3.5.2 The individual
or institution suspected of committing or attempting to commit the
alleged wrongful behavior, including all appropriate information,
such as the beneficiary’s name, sponsor’s status and Social Security Number
(SSN) or Department of Defense Benefits Number (DBN), beneficiary’s
relationship to sponsor, provider’s specialty (e.g., General Practitioner
(GP), Dental Surgeon, or Pharmacy) and identification number (e.g.,
TIN, NPI, NDCDP), address, and telephone number.
3.5.3 The suspicious
behavior uncovered (e.g., audit, prepayment screen, predictive analytics,
beneficiary, pharmacy, provider complaint, tip, Department of Defense
(DoD) Hotline, investigator notification) and the date the allegations
were initially identified.
3.5.4 A clear
summary of the behavior which is suspected to be in violation of
Federal law, regulation or policy (e.g., billing for services, pharmaceuticals
or supplies that were not provided, altering receipts or claim forms, duplicate
billing, providing incorrect information when seeking preauthorization).
3.5.5 Identifying
specific facts that illustrate the pattern or summary conclusions
(e.g., submitted probable false claims to the contractor through
the United States (US) Postal Service (USPS) or via electronic mail,
altered checks, misrepresented the description and coding of services,
falsified the name of the actual provider of care, falsified the
name of the actual pharmacy dispensing the prescription, altering
medical records).
3.5.6 All action taken during developmental
stage to include contacts made, information obtained, potential problematic
issues.
3.5.7 The number of claims or encounters,
the length of time the suspicious behavior has occurred and the Government’s
and contractor’s loss.
3.5.8 Current status of claims or
other requests submitted by the suspected provider, pharmacy or beneficiary
(e.g., regular development, processing and payment or denial, claims
suspension, prepayment review).
3.5.9 Any relevant
documents provided (e.g., any correspondence with the provider,
pharmacy or beneficiary, telephone conversation records, provider
certification files, requests for medical records, educational letters,
recoupment letters).
3.5.10 Previous or ongoing administrative
measures, or both if appropriate refer to
Section 2 (e.g.,
educational efforts, prepay review).
3.5.11 Actions taken to identify and
determine the total TRICARE exposure, including coordination with
other contractors.
3.5.12 Indicate the total monetary
exposure to TRICARE and if actual patient harm has occurred.
3.5.13 Any other facts that may establish
a pattern of practice or indicate that the provider, pharmacy or beneficiary
intended to defraud the Government or the contractor.
3.6 Copies
of Supporting Documents
3.6.1 The contractor shall include
a copy of all relevant supporting document(s) when referring cases
of potential fraud or abuse that includes the following but not
limited to (DHA PI has the option to request supporting documentation
in either paper or electronic media):
3.6.1.1 A completed DHA/Market/Military
Medical Treatment Facility (MTF) Fraud and Abuse Referral Cover Sheet
shall be submitted with the case referral. For reporting requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
3.6.1.2 All applicable TRICARE regulatory
provisions violated or if applicable, contractual requirements violated.
3.6.1.3 Copies of each claim, Explanation
Of Benefits (EOB) forms, medical records, pharmacy records, provider
certification file and other documents demonstrating the suspicious
behavior in individually labeled file folders.
3.6.1.4 Identify the most recent history
covering the most recent and relevant time period.
3.6.1.5 Any relevant documents (e.g.,
such as any correspondence with the provider, pharmacy or beneficiary,
telephone conversation records, provider certification files, requests
for medical records, educational letters, recoupment letters).
3.6.1.6 Contractor audits on the suspected
provider, pharmacy or beneficiary. Audits will include a summary spreadsheet
that clearly identifies the audit parameters, the findings for each
patient audited (or claim, depending on how the audit is set up),
and totals all applicable columns.
3.6.2 The contractor
shall include supporting documentation and patient’s claim in a
separate folder that shall be included with the individual audit
files in
Section 3. Each patient’s claim(s) that clearly
identifies, by last name, the patient and sponsor’s SSN.
3.6.2.1 Each folder shall contain the
contractor’s individual audit sheet for those claims.
3.6.2.2 Identify relevant codes but
not limited to; procedure codes, diagnosis codes, and revenue codes.
3.6.2.3 The contractor shall provide
written English Supporting documents and translated in English should the
case referral be from a foreign country at no cost to the Government.