The contractor’s
anti-fraud and abuse controls shall include the following and the
controls:
• Eligibility verifications for
beneficiaries, providers, and pharmacies.
• Coordination of Benefits (COB).
• Claims processing edits.
• Claims auditing software.
• Duplicate claims payment prevention.
• Prepayment edits (e.g., applied
to program exclusions and limitations).
• Prepayment Claims Review -
placement of providers or beneficiaries on prepayment review.
• Post-payment utilization review
to detect fraud or abuse by either beneficiaries, pharmacies, or
providers and to establish dollar loss to the Government.
• Focused reviews of services
known to have relatively high rates of fraud and abuse.
• Recoupments of overpayments
identified related to suspect claims.
• Application of security measures
to protect against embezzlement or other dishonest acts by employees.
• Incorporate anti-fraud attestation
language whenever and wherever practical (e.g., claim forms, network agreements,
provider remittance, electronic claims submission agreements, Explanation
of Benefits (EOBs)).
• Utilization of Hotlines (Fraud
Reporting Mechanisms).
• Prepayment duplicate claims
screening.
• Post-payment duplicate screening
- TRICARE Duplicate Claims System (DCS).
• Provider Enrollment - Verification
of provider status (e.g., credentials, licensure) to include appropriate termination
action when findings are discovered, recommendations of boards,
state licenses, etc. results in loss or suspension of licensure
or certification.
• PI targeted measures (e.g.,
prepayment anti-fraud review, use of post-payment fraud detection,
predictive analytics software, data mining software, routine anti-fraud
data mining, investigative anti-fraud auditing, provider and beneficiary
education).
• Controls will include cost
control review of outliers, spike in dollars paid, high utilization
of supplies, verification of beneficiary submitted claims for high
dollar to validate appropriateness, new benefit monitoring.
• Specific to pharmacy, controls
shall 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 and 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 and perform on-site of top one percent of providers
who meet these indicators.