Skip to main content

Military Health System

Utility Navigation Links

TRICARE Operations Manual 6010.62-M, April 2021
Program Integrity
Chapter 13
Section 4
Case Development
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
1.1  The contractor shall establish policies, procedures and organizational units for the purpose of preventing, detecting, developing, reporting and evaluating cases of suspected fraud and program abuse for referral to Defense Health Agency (DHA) Program Integrity (PI) in accordance with thresholds identified in Section C and actions described in this chapter.
1.1.1  The contractor shall develop priority scale on determination if a case should forego administrative controls, refer to Section 2, and coordinate with DHA PI if patient harm or abuse is determined or if egregious.
1.1.2  The contractor shall provide education to providers by certified mail. The education shall include, but limited to, how the issue was identified (e.g., probe audit, data analysis, other methods) and what the issues are.
1.1.3  The contractor shall allow at least 120 calendar days following sending by certified mail to determine what additional corrective action, administrative action, or if case development is warranted and the threshold as stated in Section C of the contract or cases with any loss where patient harm has occurred. Provider education shall occur before a case is submitted to DHA PI unless approval is obtained from DHA PI prior to case development on a case-by-case basis.
1.1.4  The contractor shall coordinate with DHA PI for all circumstances involving patient harm and cases that have been determined to meet criteria for case referral as required in paragraph 4.1.
1.1.5  The contractor shall coordinate with DHA PI before moving forward with case development.
1.1.6  The contractor shall identify the actions taken, allegations, dollar amount, and provide to DHA PI.
1.2  The contractor shall develop the case to determine the probable method of fraud and potential dollar value of the case.
1.3  The contractor shall include the provider, pharmacy, or dental numbers (e.g., Tax Identification Number (TIN), National Provider Identifier (NPI), National Council of Prescription Drug Program (NCPDP) used by that provider, pharmacy, or dentist in its review.
1.4  The contractor shall conduct an audit if there is evidence of possible fraud (e.g., failed education, repetitive occurrences of a pattern of abnormal billing).
1.5  The contractor, or its representative, shall not conduct personal interviews with beneficiaries, pharmacies, dental practices, or providers in developing potential fraud case if a case is being pursued or an active case. Interviews will be conducted, if necessary, by the appropriate Government investigative agency.
1.5.1  The contractor may contact beneficiaries and providers to obtain information during the course of their case development. For example, when performing a beneficiary inquiry (survey), the contractor may contact the beneficiary to confirm receipt or clarify response(s).
1.5.2  The contractor may ask for status of records request, clarification of the forms utilized, or clarify the types of medical records being requested when contacting a provider’s office during the medical records request or audit process to confirm receipt of the medical records request.
1.5.3  Providers and beneficiaries may be contacted for standard business purposes (e.g., prior authorizations).
2.1  If a case has been determined to warrant a case referral the contractor shall:
2.1.1  Meet with DHA PI within 30 calendar days to discuss next steps for case development.
2.1.2  Complete the case referral within 120 calendar days.
2.1.3  Refer the completed case referral to DHA PI within 30 calendar days of development completion. This timeline shall be documented in case referral.
2.1.4  Any exceptions to the above must be requested in writing and approved by the DHA PI.
2.1.5  Document the start of the 120 calendar day’s clock and provide timeline in case referral to include but not limited to initial identification, actions taken, and medical records request timeline.
2.2  The contractor shall not report fraud and abuse cases which are suspected of violating Federal law directly to the Defense Criminal Investigative Service (DCIS), Military Criminal Investigation Organizations (MCIOs), Federal Bureau of Investigation (FBI), or any other investigative organization.
2.3  The contractor shall report all cases to DHA PI in accordance with the procedures in this chapter.
2.4  Exception to the above will be if DHA PI, after collaboration with law enforcement or Department of Justice (DOJ), determines a particular violation of TRICARE rules, policies do not constitute fraud and abuse as defined in 32 CFR 199.9, or is not viable for civil or criminal prosecution.
2.5  In this circumstance, written notification will be made to the contractor identifying the specific violation(s) of TRICARE rules or policies that do not constitute fraud and abuse as defined in 32 CFR 199.9 or is not viable for civil or criminal prosecution.
2.6  The contractor shall not submit cases to DHA PI that fall below the threshold as stated in Section C of the contract without patient harm.
Note:  The determination that patient harm has occurred must be based on the opinion of a qualified medical or dental provider or pharmacist in the case of pharmacy claims.
2.7  The contractor shall coordinate administrative action (including quality interventions) if the case is under an active law enforcement investigation (federal, state or local) or if the case is being prosecuted criminally or civilly litigated or both.
3.1  DHA PI will evaluate each referred case in accordance with DHA PI criteria as outlined on the Case Referral Evaluation (CRE) form.
3.2  The contractor shall submit each case referred on paper in duplicate at no cost to the Government. Cases submitted electronically are not submitted in duplicate.
3.3  The contractor shall provide complete copies of any case files DHA PI requests (e.g., utilization reviews, patterns of practice) at no cost to the Government.
3.4   DHA PI has the option to request case referrals and supporting documentation in either paper or electronic media.
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):  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.  All applicable TRICARE regulatory provisions violated or if applicable, contractual requirements violated.  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.  Identify the most recent history covering the most recent and relevant time period.  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).  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.  Each folder shall contain the contractor’s individual audit sheet for those claims.  Identify relevant codes but not limited to; procedure codes, diagnosis codes, and revenue codes.  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.
4.1  Patient Harm And Abuse
4.1.1  The contractor shall notify DHA PI within two business days if there is a suspected patient harm and abuse issue identified.
4.1.2  The contractor shall expeditiously refer cases to DHA PI due to the sensitive nature and time regarding Patient Harm and Abuse Cases.
4.1.3  DHA PI has responsibility in coordinating patient harm and abuse cases in which a fraudulent or abusive act resulted in patient harm.
4.1.4  The contractor shall first establish by a qualified medical provider, dentist, or pharmacist (if applicable) that patient harm or abuse exists and provide to DHA PI in writing.
4.1.5  The contractor shall include the Fraud/Abuse Patient Harm Initial Notification Checklist with the written opinion, which is completed by the contractor, dental, or PBM PI Office, and is submitted to DHA PI. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.1.6  The Fraud/Abuse Patient Harm Initial Notification Checklist is the minimum amount of information needed by DHA PI.
4.1.7  DHA PI coordinates patient harm or abuse case referrals with the DHA Clinical Support Division (CSD), TRICARE Health Plan (THP), and law enforcement.
4.1.8  The contractor shall notify those beneficiaries (or their parents or guardians if underage 18 or incapacitated) who are affected in cases involving actual patient harm or abuse.
4.2  TRICARE Beneficiary Eligibility
4.2.1  The contractor shall ensure that no care be approved or claims paid for services on or after the date eligibility ended.
4.2.2  The contractor shall perform verification and search of public records to determine if an event was not reported and records need to be updated, including court records.
4.2.3  The contractor shall flag the beneficiary file to suspend all claims for services provided on or after the date eligibility reportedly ended.
4.2.4  The contractor shall immediately investigate and take action to eliminate administrative errors if there is reason to question the eligibility of a beneficiary and fraud is suspected (e.g., through correspondence, Defense Enrollment Eligibility Reporting System (DEERS) response, or contractor file data which raises some question about the eligibility of a beneficiary).
4.2.5  The contractor shall contact DMDC if the internal investigation does not resolve the possibility of fraud.
4.2.6  The contractor shall initiate action to recoup funds paid for services to beneficiaries who were not eligible and report those actions. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract to DHA PI.
4.2.7  The contractor shall handle eligibility matters that involve less than the threshold as stated in Section C of the contract.
4.2.8  The contractor shall refer those individual beneficiary eligibility cases that meet the threshold as stated in Section C of the contract upon coordination with DHA PI.
4.3  Identity Theft
4.3.1  The contractor shall handle time sensitive identity theft cases expeditiously and notification provided to DHA PI within two business days.
4.3.2  The contractor shall immediately flag the beneficiary file for prepayment review monitoring upon notification.
4.3.3  The contractor shall contact the beneficiary after flagging the file before any payment of future claims are made to verify that the claims are valid.
4.3.4  The contractor shall provide the beneficiary with a copy of their billing history along with a request that the beneficiary review the billing history information to verify the validity of past claims.
4.3.5  The contractor shall notify DHA PI regarding identity theft cases to determine if health care fraud has occurred within 10 calendar days within identification.
4.4  Contractor Coordination With Other TRICARE Contractors
4.4.1  The contractor 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.
4.4.2  The contractor shall coordinate with other contractors to ensure that the TRICARE program is protected.  This may include notifying other contractors of administrative actions of nationwide providers.  Coordinating relevant TRICARE exposure for that contractor and geographical area of responsibility during the development of case referrals.
4.4.3  The contractor PI unit who initiates the case shall contact the other contractor PI units for exposure.
4.4.4  The initiating contractor PI unit shall provide the other contractor PI units with the fraud or abuse scheme, name of provider(s) to include practice name, Tax Identification Numbers (TINs), NPI, or NCPDP provider Identification and date range so research may be conducted.
4.4.5  The initiating contractor shall inform DHA PI in the case report of these contacts and findings if suspected practice is a pattern among national or geographical area of responsibility.
4.4.6  Findings of potential fraud or abuse by another contractor shall be reported to DHA PI by the contractor who initiated the investigation.
4.4.7  The contractor involved shall notify DHA PI for the proper coordination in any situation which could lead to duplicate investigative efforts.  The contractor that initiated the case first shall submit joint case referrals.  Each contractor with exposure shall conduct an independent audit; all findings shall be submitted by the initiating contractor PI unit.
4.4.8  The contractor shall elevate those issues that cannot be resolved at the operational level between the contractors to DHA PI for resolution.
4.5  Possible Forgery of Check Endorsement
4.5.1  The contractor shall report to DHA PI within two business days cases involving forgery and other unusual circumstances. Such circumstances might include a suspicion that the forgery involves contractor employee fraud or a pattern of forgery suggesting an organized effort.
4.5.2  The contractor shall immediately initiate reclamation proceedings to have its bank credit the amount of the forged check to the account when the payee of a benefits check alleges that the endorsement on the check was forged.
4.5.3  The contractor shall accomplish the following in possible forgery of check endorsements cases:  Request the payee submit an affidavit of the forgery. Affidavit of forgery forms can usually be obtained from the bank.  Explain to the payee when requesting the payee to complete the affidavit that the issuance of a replacement check is contingent upon timely return of the completed affidavit and receiving a credit on the forged check.  Forward the completed affidavit along with the original of the allegedly forged check, to the contractor’s bank with a request that the bank credit the amount of the forged check to the contractor’s account.  Under the Uniform Commercial Code (UCC), generally adopted by all states, a bank is liable for cashing a forged check and must credit the payment back to the account upon which the check was drawn when the forged check affidavit, executed by the payee, is received.  Issue a replacement check to the payee when the bank sends notice that it has credited the account for the amount of the forged check.  Rely upon the bank for appropriate referral of the matter for investigation by state authorities since the forgery of a contractor check is a violation of state and federal law. It is generally more efficient for local authorities to handle such matters.  Cooperate with the state authorities in their investigating efforts.  Direct questions concerning the release of information to state authorities in these cases to DHA Office of General Council (OGC).
4.6  Time Limits
4.6.1  The contractor shall take timely action within five business days. While the UCC holds the bank strictly liable for cashing forged checks, the states have generally adopted statutes of limitation relieving the banks of liability for any reclamation action not initiated within a specified time.
4.6.2  These time limits generally vary from one to three years. Therefore, it is essential that the contractor promptly act upon notice that a payee did not receive a check or upon notice of an alleged forgery.
- END -
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery