1.0 SCOPE AND PURPOSE
1.1 This section specifies which
individuals and entities may, or in some cases must, be excluded
from the TRICARE program. It outlines the authority given to the
Department of Health and Human Services/Office of Inspector General
(DHHS/OIG) to impose exclusions from all Federal health care programs,
including TRICARE.
1.2 This section
also outlines the Defense Health Agency (DHA) authority for exclusions
and terminations.
1.3 In addition, this section states
the effect of exclusion, factors considered in determining the length
of exclusion, and provisions governing notices, determinations,
and appeals.
1.4 This section also outlines
procedures and protocol for suspension of claims processing, conflict
of interest, Voluntary Self-Disclosure protocol, and provider self-reported
refunds.
2.0 DHA AUTHORITY FOR SUSPENSION
OF CLAIMS PROCESSING
2.1 DHA may suspend claims processing
based on
32 CFR 199.9 provisions.
2.2 The Director,
DHA or designee may suspend claims processing without prior notification
to the provider or beneficiary of the intent to suspend payments.
2.2.1 Within
30 calendar days of the claims suspension, DHA will provide written
notice advising the beneficiary or provider that a temporary suspension
has been ordered and a statement of the basis of the decision to
suspend payment.
2.2.2 The suspension of claims processing
will be for a temporary period pending the completion of investigation
and any ensuing legal or administrative proceedings, unless sooner
terminated by the Director, DHA or designee. See
32
CFR 199.9 for additional guidance.
2.2.3 DHA Program
Integrity Office (PI) is responsible for advising the contractor
of any suspension of claims processing.
3.0 DHA AUTHORITY FOR EXCLUSIONS
AND TERMINATIONS
3.1 DHA may exclude any individual
or entity based on
32 CFR 199.9 provisions.
3.2 The contractor
shall provide written notice to DHA PI within 10 calendar days of
any situation involving a TRICARE provider, pharmacy, or entity
whose actions warrant exclusion under DHA authority related to fraudulent or
abusive behavior.
3.3 The Director, DHA or designee,
has the authority to exclude an authorized TRICARE provider, pharmacy, or
entity. The period of exclusion is at the discretion of DHA. (See
32
CFR 199.9.)
3.4 DHA PI is responsible for coordinating
and issuing notification of exclusion action. DHA PI will send written
notice to the provider of the proposed exclusion, and the potential
effect thereof. The individual or entity may submit evidence and
written argument regarding the proposed exclusion.
3.5 DHA PI has sole authority to
issue an Initial Determination of Exclusion. Written notice of this
decision will include the basis for the exclusion, the length of
the exclusion, as well as the effect of the exclusion. The determination
also outlines the earliest date on which DHA PI will consider a
request for reinstatement, the requirements for reinstatement, and
appeal rights available.
3.5.1 DHA PI will notify appropriate
agencies, including contractors, of all DHA exclusion actions taken.
3.5.2 DHA PI
will be responsible for initiating action based on reversed or vacated
decisions. Exclusion of a provider, pharmacy, or entity will be
effective 15 calendar days from the date of the initial determination.
3.5.3 The Director,
DHA or designee has sole authority for approval of any request for
reinstatement.
4.0 CONTRACTOR
ACTIONS UNDER TRICARE EXCLUSION AUTHORITY -
32
CFR 199.94.1 The contractor shall provide
supporting documentation to DHA PI within 10 calendar days when recommending
any provider exclusion.
4.2 DHA PI will notify the contractor
of an exclusion action.
4.3 The contractor shall:
4.3.1 Ensure that no payment is made
to an excluded provider, pharmacy, or entity for care provided on
or after the date of the DHA action (15 calendar days from the date
of the Initial Determination as noted in
paragraph 3.5). Neither the
provider, pharmacy, entity, nor the patient will be entitled to
TRICARE cost-sharing once the exclusion is in effect.
4.3.2 Notify
DHA PI if a provider, pharmacy, or entity attempts to bill the program
after the effective date of exclusion.
4.3.3 Ensure
that an excluded provider, pharmacy, or entity is not included in
the network and provider directory.
4.3.3.1 The contractor shall ensure
that the network provider, pharmacy, or entity whose contract has
been canceled clearly understands his or her status if cancellation
of a network provider, pharmacy, or entity agreement is required.
4.3.3.2 Provide written notice within
15 business days, sent by certified mail, return receipt requested,
that the network provider’s or network pharmacy’s agreement has
been canceled.
4.3.3.3 Provide DHA PI a copy within
15 business days.
4.3.4 Notify,
in writing within 10 calendar days, the beneficiary who submitted
a claim that the provider has been excluded from the TRICARE program.
4.3.5 Ensure
the enforcement of all exclusion action taken, and notify appropriate
parties of the application of exclusions. For example, any claim
received from an excluded third party billing agent shall be returned
to the provider with instructions to resubmit the claim directly
or through another third party billing agent. The provider remains
entitled to reimbursement for covered services as long as they remain
an authorized TRICARE provider.
5.0 DHHS/OIG
APPLICATION OF SANCTION AUTHORITY
5.1 DHHS/OIG can exclude individuals
or entities from participation in any federal health care program
to include the Department of Defense (DoD) Military Health System
(MHS), and TRICARE. Authority and exclusion categories can be found
on the DHHS/OIG website.
5.2 DHHS/OIG has sole responsibility
for issuing a written notice of its intent to exclude a provider,
pharmacy, or entity, the basis for the exclusion, the effective
date, the period of exclusion, and the potential effect of exclusion.
5.3 DHHS/OIG
has sole authority for terminating an exclusion imposed under their
authority. DHHS/OIG will handle notifications of approval or denial
of a request for reinstatement and are responsible for reversing
or vacating decisions.
5.4 DHHS/OIG exclusions and reinstatements
are issued on a monthly basis. DHHS/OIG will provide DHA PI with
immediate access to this information, which will be forwarded to
each contractor.
5.5 Exclusions taken by DHHS/OIG
are binding on Medicare, Medicaid, and all Federal health care programs with
the exception of the Federal Employee Health Benefit Program (FEHBP)
(42 USC 1320a-7b(f)). No payment will be made for any item or service
furnished on or after the effective date of exclusion until an individual
or entity is reinstated by DHHS/OIG, and subsequently meets the
requirements under
32 CFR 199.6.
6.0 CONTRACTOR
ACTIONS UNDER DHHS/OIG EXCLUSION AUTHORITY
6.1 DHA PI
will provide the contractor the monthly issuance of DHHS/OIG exclusion
and reinstatement actions.
6.2 The contractor shall ensure
that no payment is made to an excluded provider, network pharmacy,
or entity for care provided on or after the date of the DHHS/OIG
action. The provider, pharmacy, or entity, nor the patient will
not be entitled to TRICARE cost-sharing once the exclusion is effective.
6.2.1 The contractor
shall notify DHA PI should a provider, network pharmacy, or entity
attempt to bill the program or if payment has been issued after
the effective date of exclusion.
6.2.2 It is
not necessary for the contractor to issue a separate letter notifying
the provider, network pharmacy, or entity of the exclusion action.
6.3 The contractor shall ensure
that an excluded provider, pharmacy, or entity is not included in
the network.
6.3.1 The contractor shall ensure
that the network provider or network pharmacy whose contract has
been canceled understands his or her status, if the cancellation
of a network, or if applicable, participating provider agreement
is required.
6.3.2 The contractor shall accomplish
this by providing written notice, within seven calendar days, sent
by certified mail, return receipt requested, that the network provider’s
or network pharmacy’s agreement has been canceled.
6.3.3 The contractor
shall send a copy to DHA PI within seven calendar days.
7.0 CONTRACTOR
APPLICATION OF SANCTION AUTHORITY
7.1 The contractor shall ensure
the enforcement of all sanction action(s) taken, and notify appropriate
parties of the application of sanctions. For example, any claim
received from an excluded third party billing agent shall be returned
to the provider with instructions to resubmit the claim directly
or through another third party billing agent.
7.2 The provider
remains entitled to reimbursement for covered services as long as
they remain an authorized TRICARE provider.
8.0 PROVIDER,
NETWORK PHARMACY, OR ENTITY TERMINATION OF AUTHORIZED PROVIDER STATUS
8.1 The contractor
shall terminate the authorized provider status of any provider,
network pharmacy, or entity determined not to meet program requirements.
The request for reinstatement will be processed under the procedures
established for initial requests for authorized provider or network
pharmacy status. See
paragraph 10.0 for further information.
8.2 Other
Listings
Other
listings of actions affecting provider authorization status (e.g.,
Federation of State Medical Boards of the United States (US)) will
be sent to each contractor. A provider who has licenses to practice
in two or more jurisdictions and has one or more licenses suspended
or revoked shall be terminated as a TRICARE provider in all jurisdictions.
9.0 CONTRACTOR
REQUIREMENTS FOR TERMINATION
9.1 The contractor shall initiate
termination action based on a finding that the provider, pharmacy,
or entity does not meet the qualifications to be an authorized provider
when status as an authorized provider, authorized network pharmacy
or authorized entity is ended.
9.2 Separate
termination action by the contractor is not required for a provider,
pharmacy, or entity sanctioned under the exclusion authority granted
DHHS/OIG.
9.3 The period of termination will
be indefinite and will end only after the provider, pharmacy, or
entity has successfully met the established qualifications for authorized
status under TRICARE and has been reinstated as outlined in
paragraph 10.0.
9.4 The contractor
shall notify the provider, pharmacy, or entity in writing of the
proposed action to terminate them.
9.4.1 The contractor shall specifically
notify the provider, pharmacy, or entity of the proposed action
to terminate their status as an authorized TRICARE provider when
the provider, pharmacy, or entity falls within the contractor’s
certifying responsibility and the provider, pharmacy, or entity
fails to meet the requirements of
32
CFR 199.6 (
Addendum A, Figure 13.A-9).
9.4.1.1 The contractor shall not terminate
the provider, pharmacy, or entity when he or she fails to return certification
packets but flag the provider as ‘inactive’.
9.4.1.2 The contractor is not required
to send a copy of the notice to DHA PI.
9.4.1.3 The contractor shall send the
notice to the provider’s, pharmacy’s or entity’s last known business
or office address.
9.4.2 The pharmacy
contractor shall notify the pharmacy in writing of the proposed
action to terminate the pharmacy status as a network pharmacy when
it is not in compliance with its agreement and the pharmacy fails
to meet the requirements of
32 CFR 199.6 (
Addendum A, Figure 13.A-9).
9.4.3 The notice
shall state that the provider, pharmacy, or entity will be terminated
as of the effective date of the termination notice.
9.4.4 The notice
shall also inform the provider, pharmacy, or entity of the situation(s)
or action(s) which form the basis for the proposed termination.
9.4.5 For network
providers, the notice shall inform the provider that his or her
patients will be referred to another provider pending final action.
9.4.6 For a
network pharmacy, the notice shall inform the pharmacy that beneficiary
prescriptions may not be filled and any claims submitted will be
denied.
9.4.7 The notice shall offer the
provider, pharmacy, or entity an opportunity to respond within 30
calendar days from the date of the notice. An extension to 60 calendar
days may be granted if a written request is received during the
30 calendar days showing good cause.
9.4.8 The provider,
pharmacy, or entity may respond with either documentary evidence
and written argument contesting the proposed action or a written
request to present in person evidence or argument to a contractor’s
designee at the contractor’s location. Expenses incurred by the
provider, pharmacy, or entity are their responsibility.
9.4.9 Once the
notice of proposed action to terminate is sent, the provider’s claims
will be suspended from claims processing until an Initial Determination
is issued. The provider, pharmacy, or entity will be notified via
the proposed notice that the claims will be suspended from claims
processing. However, beneficiaries will not be notified of the suspension.
9.4.10 For pharmacy claims, once the
notice of proposed action to terminate is sent, the pharmacy’s claims will
not be processed as network claims until an Initial Determination
is issued.
9.4.10.1 The pharmacy will be notified
via the notice that the claims will not be processed as network
claims.
9.4.10.2 Beneficiaries will be advised
by the pharmacy that it is no longer a network pharmacy and that
any prescription filled there will require submittal of a claim
for reimbursement by the beneficiary.
9.5 Initial
Determination
9.5.1 The contractor shall invoke
an administrative remedy of termination if after the provider, pharmacy,
or entity has exhausted, or failed to comply with the procedures
for appealing the proposed termination and the decision to terminate
remains unchanged.
9.5.2 The contractor shall accomplish
this by issuing a written notice of the Initial Determination via
certified mail to the effective entity.
9.5.3 The contractor
shall send a copy of the Initial Determination to DHA PI along with
supporting documentation within seven calendar days.
9.5.4 The contractor
shall include the following in the Initial Determination written
notice:
9.5.4.1 A Unique Identification Number
(UIN) indicating the fiscal year of the Initial Determination, a consecutive
number within that fiscal year and the contractor’s name. A sample
letter is found at
Addendum A, Figure 13.A-10.
9.5.4.2 A statement of the action being
invoked and the effective date of the action. The effective date
shall be the date the provider, pharmacy, or entity no longer meets
the regulatory requirements. If there is no documentation the provider
ever met the requirements, the effective date will be either June
10, 1977 (the effective date of the Regulation) or the date on which
the provider, pharmacy or entity was first approved, whichever date
is later. In the case of a pharmacy, it would be the date on which
the pharmacy first became part of the network.
9.5.4.3 A statement of the facts, circumstances,
or actions that form the basis for the termination and a discussion
of any information submitted by the provider, pharmacy, or entity
relevant to the termination.
9.5.4.4 A statement of the provider’s,
pharmacies, or entity’s right to appeal.
9.5.4.5 The requirements and procedures
for reinstatement.
9.6 Providers
Failing To Return Recertification Documentation
9.6.1 The contractor
shall not terminate the provider, pharmacy, or entity failing to
return recertification documentation but shall be placed on the
inactive provider listing.
9.6.2 The contractor
shall first verify that the recertification package was mailed to
the correct address and was not returned by the US Postal Service
(USPS).
9.6.3 The contractor shall ensure
that no claims are paid and shall deny claims for services regardless
of who submits the claim.
9.6.4 The contractor
shall advise the provider, pharmacy, or entity shall be advised
that such action will be taken within 15 calendar days.
9.7 Requirement
To Recoup Erroneous Payments
9.7.1 The contractor shall, after
the Initial Determination letter has been issued, initiate recoupment
in accordance with
Chapter 10, Section 2 for
any claims cost-shared, paid for services, or supplies furnished
by the provider (including pharmacies) on or after the effective
date of termination, even when the effective date is retroactive,
unless a specified exception is provided by 32 CFR 199. This also
applies to claims processed by previous contractor(s).
9.7.2 The contractor
shall transfer all monies recouped, including those paid by previous
contractor(s), to DHA Contract Resource Management (CRM) in accordance
with
Chapter 3.
9.8 File
Requirements For A Terminated Provider, Pharmacy, Or Entity
The contractor shall include
the following in the Initial Determination file for the provider,
pharmacy, or entity:
9.8.1 Initial Determination of Termination
Action as well as Proposed Notice to Terminate.
9.8.2 Provider
certification file (i.e., the documentation upon which the original
certification of the provider was based) or network pharmacy agreement.
9.8.3 All correspondence
and documentation relating to the termination (copies of the enclosures
must be attached to the copy of the original correspondence).
9.8.4 Documentation
that the contractor considered or relied upon for issuing the determination.
9.9 Special
Action or Notice Requirements When An Institution Is Terminated
9.9.1 The contractor
shall take appropriate action when a DHA determination is made that
an institutional provider does not meet qualifications or standards
to be an authorized TRICARE provider.
9.9.2 Provider
And Beneficiary Notification
9.9.3 The contractor
shall:
9.9.3.1 Instruct the institution by
certified mail to immediately give written notice of the termination
to any TRICARE beneficiary (or his or her parent, guardian, or other
representative) admitted to or receiving care at the institution
on or after the effective date of the termination.
9.9.3.2 Notify any beneficiary (or
their parent, guardian, or other representative) admitted prior
to the date of the termination by certified mail that TRICARE cost-sharing
ended as of the termination date when the termination effective
date is after the date of the initial determination.
9.9.3.3 Advise the beneficiary (or
their parent, guardian, or other representative) of their financial
liability.
9.9.3.4 Use a fast, effective means
of notice (e.g., phone, fax, express mail, or regular mail, depending
on the circumstances).
9.9.3.5 Notify any beneficiary (or
his or her parent, guardian, or other representative) admitted prior
to the grace period of the violation that TRICARE cost-sharing of
covered care will continue during that period. Cost-sharing is to
continue through the last day of the month following the month in
which the institution is terminated if an institution is granted
a grace period to effect correction of a minor violation.
9.9.3.6 Notify any beneficiary (or
their parent, guardian, or other representative) admitted prior
to a grace period of the institution’s corrective action, when such
has been determined to have occurred, and the continuation of the
institution as an authorized TRICARE provider.
9.9.4 Cost-Sharing
Actions
9.9.5 The contractor shall deny cost-sharing
for any:
9.9.5.1 New patient admitted after
the effective date of the termination.
9.9.5.2 Beneficiary admitted during
a grace period granted an institution involved in a minor violation.
9.9.5.3 Beneficiary already in an institution
involved in a major violation beginning with the effective date
of the termination.
10.0 PROVIDER REINSTATEMENTS
10.1 Reinstatement
of an excluded individual or entity is not automatic once the specified
period of exclusion ends.
10.2 The individual or entity must
apply for reinstatement and receive written notice from DHA that reinstatement
has been granted.
10.3 32
CFR 199.9 provides that the Director, DHA or a designee,
will have the authority to reinstate providers, pharmacies, or entities
previously excluded or terminated under TRICARE. For providers sanctioned
by Department of Health and Human Services (DHHS), see
paragraph 3.0.
10.4 DHHS/OIG
provides monthly updates for reinstated providers, individuals,
pharmacies, and entities. The information includes exclusion date
and reinstatement date when a previously excluded provider, pharmacy,
or entity is reinstated by DHHS/OIG.
10.5 The contractor
shall, before initiating reinstatement action:
10.5.1 Determine if any erroneous
payments have been made to provider, pharmacy or entity
during period of sanction.
10.5.1.1 The contractor shall certify
the provider, pharmacy or entity as an authorized provider, and
determine the effective date of the reinstatement if no funds have
been paid for services to the provider while excluded or are otherwise
owed the Government for claims paid prior to the exclusion.
10.5.1.2 If erroneous payments have
been made to a provider, pharmacy, or entity during the period of exclusion,
restitution of the payments shall be made before a request for reinstatement
will be considered.
10.5.1.3 The contractor shall determine,
if any payments have been made, and initiate restitution of the payments.
10.5.2 The contractor shall send the
certification package to the provider, entity, or pharmacy for completion to
ensure that the provider meets the requirements to be an authorized
TRICARE provider under
32 CFR 199.6.
10.5.3 Verify that pharmacies has
all required state licenses to operate as a pharmacy.
10.5.4 Ensure the exclusion or suspension
shall remain in effect until the provider completes and returns
the certification package and the determination is made by the contractor
that the provider meets the requirements of an authorized TRICARE
provider under
32 CFR 199.6.
10.5.5 Provide in writing of the reinstatement
date, once the determination is made that the provider meets the
requirements of a TRICARE Authorized provider under
32
CFR 199.6.
10.5.6 If pharmacy, provide in writing
that the pharmacy has met the state licensing requirements and advise the
pharmacy of the date it is eligible to negotiate a new network agreement
with the contractor, as determined by DHA.
10.6 The contractor
shall notify the provider in writing with an explanation on why
the provider did not meet the requirements and advise the provider
of their appeal rights if the provider does not meet the requirements
of a TRICARE Authorized Provider under
32
CFR 199.6.
10.6.1 The contractor shall provide
DHA PI a copy of the letter within seven calendar days.
10.6.2 The contractor shall provide
in writing to the pharmacy within seven calendar days, that the
pharmacy does not have the required state licenses and provide notification
to the pharmacy why the pharmacy is not eligible to be a network
pharmacy and advise pharmacy of appeal rights.
10.6.3 A copy of the letter shall
be provided to the DHA PI within seven calendar days.
10.6.4 The contractor shall provide
notification to Beneficiary Counseling and Assistance Coordinators (BCACs)
at Markets/Military Medical Treatment Facilities (MTFs) within the
provider’s service area of provider status within seven calendar
days.
11.0 CONFLICT
OF INTEREST
11.1 The contractor shall document
and refer suspected violations of conflict of interest to the DHA
PI within 15 calendar days.
11.1.1 Conflict of interest includes
any situation where an active duty member of the Uniformed Services (including
a reserve member while on active duty, active duty for training,
or inactive duty training) or civilian employee (which includes
employees of the Department of Veterans Affairs/Veterans Health
Administration (DVA/VHA)) of the US Government, through an official
federal position has the apparent or actual opportunity to exert, directly
or indirectly, any influence on the referral of beneficiaries to
himself or herself or others with some potential for personal gain
or the appearance of impropriety.
11.1.2 Although individuals under
contract to the Uniformed Services are not considered employees,
such individuals are subject to conflict of interest provisions
by express terms of their contracts and, for purposes of the
32
CFR 199.9 may be considered to be involved in conflict
of interest situations as a result of their contract positions.
11.1.3 In any situation involving
potential conflict of interest of a Uniformed Service employee,
the Director, DHA, or a designee, may refer the case to the Uniformed
Service concerned for review and action.
11.2 Federal
Employees And Active Duty Military
11.2.1 32
CFR 199.6 prohibits active duty members of the Uniformed
Services or employees (including part-time or intermittent), appointed
in the civil service of the US Government, from authorized TRICARE
provider status.
11.2.2 This prohibition applies to
TRICARE payments for care furnished to TRICARE beneficiaries by
active duty members of the Uniformed Services or civilian employees
of the Government.
11.2.3 The prohibition does not apply
to individuals under contract to the Uniformed Services or the Government.
11.3 Exceptions
11.3.1 National
Health Service Corps
TRICARE
payment may be made for services furnished by organizations to which
physicians of the National Health Service Corps (NHSC) are assigned.
However, direct payments to the NHSC physician are prohibited by
the dual compensation provisions.
11.3.2 Emergency
Rooms
11.3.2.1 Any off-duty Government medical
personnel employed in an emergency room of an acute care hospital
will be presumed not to have had the opportunity to exert, directly
or indirectly, any influence on the referral of TRICARE beneficiaries;
therefore, TRICARE payments may be made to the employing hospital
provided the medical care was not furnished directly by the off-duty
Government medical personnel in violation of dual compensation provisions.
11.3.2.2 The contractor shall not cost-share
professional services by the provider since they cannot be recognized
as TRICARE-authorized providers.
11.3.3 Reserves
Generally Exempt
11.3.3.1 Conflict of interest provisions
do not apply to medical personnel who are Reserve members of the Uniformed
Services or who are employed by the Uniformed Services through personal
services contracts, including contract surgeons.
11.3.3.2 Although Reserve members, not
on active duty, and personal service contract medical personnel
are subject to certain conflict of interest provisions by express
terms of their membership or contract with the Uniformed Services,
resolution of any apparent conflict of interest issues which concern
such medical personnel is the responsibility of the Uniformed Services,
not the DHA.
11.3.3.3 National Guard and reservists
on active duty are not exempt during the period of their active
duty commitment.
11.3.4 Part-Time Physician Employees
Of The US Government
11.3.5 Referrals
From Uniformed Services Facilities
11.3.5.1 Referrals from Uniformed Services
facilities to individual civilian providers should, in every practical instance,
be made to participating providers. However, referrals of TRICARE
beneficiaries by Uniformed Services personnel to selected individual
providers in the civilian community when other similar participating
providers are available may involve a conflict of interest.
11.3.5.2 The contractor shall document
any apparent problem of this nature and refer the case to the DHA
PI for investigation.
11.3.5.3 In any situation involving
potential conflict of interest of a Uniformed Service employee,
the Director, DHA, or a designee, may refer the case to the Uniformed
Service concerned for review and action.
12.0 REPORTING
PROVIDER REFUNDS - PROVIDER REFUNDS (SINGLE CLAIM AND MULTIPLE CLAIMS)
12.1 Providers
have a requirement to return overpayments to the TRICARE program
(voluntary or requested). Possible reasons for provider refunds
(single or multiple claims) may include: Other Health Insurance
(OHI), Third Party Liability (TPL), Payment sent to incorrect provider,
Duplicate Payment, Provider Billing Error, or TRICARE overpaid.
12.2 The contractor
shall notify DHA PI within 30 business days of receiving reported
refund when a Provider Billing Error refund is made to the contractor
(single or multiple).
12.3 For reporting submission requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
13.0 VOLUNTARY
SELF-DISCLOSURE
13.1 Congress through the Fraud
Enforcement and Recovery Act of 2009 (FERA) amended the False Claims
Act (FCA) to cover the identification and return of overpayments
to federal programs. Specifically, FERA expanded the scope of the
FCA to provide liability for “knowingly” retaining an overpayment.
Accordingly, the FCA now imposes liability on any provider who received
overpayments (accidentally or otherwise) and then knowingly fails
to return the overpayment to the Government. The amended statute
allows for knowingly retaining an overpayment to be the sole allegation
of a complaint under the FCA. Additionally, failure to timely report
and return an overpayment under the amended FCA exposes a provider
to liability. This includes TRICARE claims and payments.
13.2 Individuals
or entities who wish to voluntarily disclose self-discovered potential
fraud to DHA-PI may do so under the Self-Disclosure Program (SDP).
Disclosing parties may report by sending to DHA PI or may also report online.
13.3 Non-health
care matters, should be reported to the DHA Office of Inspector
General (OIG) Hotline, or if military, to the DoD OIG Hotline or
the respective military service OIG Hotline.
13.4 Disclosing
parties already subject to a Government inquiry (including investigations,
audits, or other oversight activities) are not automatically precluded
from using the SDP. The disclosure, however, must be made in good
faith and must not be an attempt to circumvent any ongoing inquiry.
Disclosing parties under Corporate Integrity Agreements (CIA) with
DHA may also use the SDP in addition to making any reports required
in the CIA.
13.5 Disclosing parties are advised
that the self-disclosure may be shared with other Federal agencies.