1.0 Contractor's Program Integrity
(PI) responsibility
1.1 The contractor shall incorporate
into its organizational management philosophy a published corporate
strategy that underlines commitment to health care fraud detection
and prevention. The strategy, developed and endorsed by corporate
management, shall include maintaining a focus on increased health
care fraud awareness, developing processes which identify fraud,
referring health care fraud cases, assisting in the prosecution
of the cases, and developing deterrents to health care fraud. Internal
procedures shall be in place for all offices to provide potential
fraud and abuse cases to the contractor’s PI function. The corresponding
Contract Data Requirements List (CDRL) DD Form 1423 provides details
on the contents and submission of the strategy and internal procedures
to include the published corporate strategy.
1.2 PI is a contractor responsibility
to ensure that necessary medical, pharmacy, and dental services are
provided only to eligible beneficiaries by authorized providers
or reimbursement made to eligible beneficiaries or providers under
existing law, Regulation and Defense Health Agency (DHA) instructions.
Further, the PI responsibility extends to applying the expertise
of the contractor staff to the evaluation of the quality of care,
and to ensure that payment is made for care which is in keeping with
generally accepted standards of medical, pharmacy, or dental practice.
In carrying out this function, the contractor is required to apply
all the standards and requirements addressed in this and all other
chapters of this manual. The contractor shall have a dedicated PI
function, solely for the Government line of business, which shall
perform the PI activities listed below and shall respond to requests
and direction from DHA Program Integrity Office (PI).
1.3
Use
of Anti-Fraud Analytics
Contractor
shall perform analyses of professional and institutional health
care data associated with type, frequency, duration and extent of
services, to identify patterns of fraudulent or abusive practices by
providers and/or beneficiaries. Anti-fraud software program(s) must
include both expert (rules-based) and predictive analytics/modeling
components. Software must have fraud detection rules-based logic,
fraud detection analytics, predictive modeling, and statistical
algorithm capabilities, along with the ability to produce comprehensive
fraud detection reports and metrics. In order to be considered predictive,
the software must not be limited to only expert or rules based logic,
and must include more advanced analytical techniques such as artificial
intelligence, machine learning, and regression techniques. Predictive
analytical/modeling software must be used both pre-pay (before claims
are paid) and post-pay (after claims are paid) for the purposes
of fraud detection. The application must be on-line and accessible
by the contractor’s Program Integrity Unit fraud specialists. This paragraph
is not applicable to the TRICARE Dual Eligibility Fiscal Intermediary
Contract (TDEFIC).
1.4 Anti-Fraud
Support
1.4.1 Technical and professional
consultation and information shall be provided by the contractor
(to include documentation) as directed by DHA PI concerning:
• Delivery of health care services
in the Continental United States (CONUS) (or outside of the Continental
United States (OCONUS) when applicable).
• Submission, adjudication and
reimbursement of claims for health care services, pharmacy or dental services.
• TRICARE operations and benefits.
• Anti-fraud activities.
1.4.2 Investigating and prosecuting
support shall be provided by the contractor to include documents,
reports, correspondence, and other applicable data or items.
1.4.3 Documents, reports, correspondence,
and other applicable data or items shall be provided by the contractor
in support of compliance monitoring, oversight activities, or other
PI related issues.
1.4.4 Case specific
data required during development and investigative process shall
be provided by the contractor (i.e., initiated by contractor, law
enforcement, Department of Justice (DOJ), or DHA PI).
1.4.5 At DHA PI’s request, the contractor
must identify and provide expert(s) or program witness(es) at Grand
Jury hearings, criminal trials, civil hearings/depositions and administrative hearings.
An expert witness is an individual having acquired a special skill
or knowledge through training or experience on a particular subject
being discussed. In addition, the types of expert witnesses that
are covered by this section are either individuals including PI
specialists who worked on the case or an expert in PI functions
who could testify as to the PI issues involved in the case. This
also includes medical experts if medical experts were used in the
case development. A prosecutor or defense attorney may request that
a witness be declared an “expert witness” based on their knowledge,
such as someone from the policy department or the contractor’s claims
processing section. Travel and per diem costs of witnesses subpoenaed
by DOJ will be paid by DOJ in accordance with Federal guidelines.
1.4.6 Claims data shall be provided
by the contractor in customary electronic format/media compliant
with the Health Insurance Portability and Accountability Act (HIPAA).
Other documentation or data to be provided may include, but is not
limited to, the original or copies of claims, explanations of benefits,
original or copies of checks (front and back), provider certification
forms, correspondence, medical records, audit records/findings,
or any other relevant information as requested (such as documents
from other offices/units). The contractor shall have dedicated personnel
and resources available to meet the timeliness requirement as directed
by DHA PI for retrieval, transmission, and/or mailing of the information.
1.4.7 The contractor shall have the
ability to electronically transfer all files, imaged documents, data,
and supporting documents, to include case referrals in a manner
that conforms with Government security protocols (e.g., protecting
Protected Health Information (PHI)/Personally Identifiable Information
(PII)).
1.4.8 The contractor shall ensure
compliance with the Alcohol, Drug Abuse and Mental Health Administration
(ADAMHA) Reorganization Act, Public Law 102-321 (July 10, 1992)
and implementing regulations including 42 CFR Part 2, when data
requested includes services related to substance abuse or mental
health.
1.5 The contractor
shall develop and maintain standard operating procedures related
to requirements/activities within this chapter (e.g., desk procedures).
A copy, in electronic read-only format, shall be provided to DHA
PI at the start of the contract with updates provided as changes
occur. The corresponding CDRL, DD Form 1423, provides details of
the contents and submission of this report.
2.0 Roles And Responsibilities
Of Cooperating Components
2.1 DHA
The Director, DHA, and designees
administer the TRICARE program in accordance with Title 10, Chapter 55,
United States Code (USC), “Medical and Dental Care,” 32 CFR 199,
and other applicable laws, regulations, directives and instructions.
2.2 DHA PI
DHA PI is responsible for anti-fraud
and abuse activities to protect benefit dollars and safeguard eligible beneficiaries.
DHA PI is the central coordinating office for allegations of fraud
and abuse against the TRICARE program and is responsible for developing
and executing anti-fraud and abuse policies and procedures, provides
oversight of contractor PI activities, supports investigative activities,
develops cases for criminal prosecution and civil litigation, and
initiates administrative measures. DHA PI also exchanges information
with DOJ, law enforcement agencies, and federal/state agencies.
2.3 DHA Office of General Counsel
(OGC)
DHA OGC
is responsible for providing legal counsel and legal services to
DHA. It is the principal point of contact on all legal matters involving
the DOJ and its Federal Bureau of Investigation (FBI). This office serves
as DOJ’s primary contact point in civil litigation involving benefit
funds. DHA OGC is also responsible for actions pursued under the
Program Fraud Civil Remedies Act (PFCRA), overseeing contractor
PI activities, supporting investigations, developing cases for civil
prosecution and civil litigation, and initiating administrative
measures. Settlements that affect the agency (e.g., civil settlement,
a provider’s or pharmacy’s TRICARE status, sanctions, etc.) shall
be coordinated with and approved by a DHA representative.
2.4 Department Of Defense Inspector
General (DoDIG)
DoDIG
has the responsibility to conduct, supervise, monitor, and initiate
investigations relating to fraud within the DoD. This authority
specifically includes DHA, its employees, contractors and subcontractors. This
authority is not limited by the type of contract which has been
entered into by the Director, DHA. All contractor, managed care,
consultant, service, and other types of contracts are subject to
the audit, investigation and evaluation authority of the DoDIG.
2.5 Defense Criminal Investigative
Service (DCIS) Of The DoDIG
DCIS is responsible for all
fraud and/or abuse investigations involving the Secretary of Defense,
the Office of the Joint Chiefs of Staff (JCOS), the Defense Agencies
(including the DHA), and any other fraud investigation deemed appropriate
by the DoDIG or designated representative. DCIS has primary investigative
jurisdiction for cases concerning alleged TRICARE fraud/abuse. This
includes cases that may involve the use of facilities by medical
providers on military installations and managed care cases (to include
network providers or network pharmacies).
2.6 Military Criminal Investigation
Organizations (MCIOs)
The MCIOs
include the United States Army Criminal Investigative Division (USACID),
Naval Criminal Investigative Service (NCIS), United States (U.S.)
Air Force Office of Special Investigations (AFOSI), U.S. Coast Guard
(USCG) Investigations and Health and Human Services (HHS) Inspector
General’s Office (for the United States Public Health Service (USPHS)).
The MCIOs have jurisdiction to investigate cases concerning alleged
fraud by active duty military Service members and their family members
who have received health care services, and retired services members
and their family members.
2.7 Defense
Contract Audit Agency (DCAA)
Upon request, the DCAA provides
audit assistance to DHA DCIS and MCIOs.
2.8 DOJ And U.S. Attorneys’ Offices
(USAO)
The DOJ,
acting through its Civil and Criminal Divisions, and the USAO have
responsibility for litigation and prosecution of cases involving
violation of the civil and criminal laws of the U.S. DOJ has jurisdiction
for federal criminal and civil action.
2.9 FBI
The FBI is the principal investigative
arm of the DOJ. It has primary responsibility for investigating federal
employee bribery and conflict of interest cases and other violations
of Federal law except those that have been assigned by law or otherwise
to another Federal agency. In addition, it has the authority to
investigate Federal agencies, Federal contractors, and Federal program
fraud such as the submission of fraudulent TRICARE claims.
3.0 Coordination And Support: Other
Contractors And External Agencies
3.1 Contractor
Coordination With Other TRICARE Contractors
3.1.1 Contractors
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. The contractor PI unit who initiates
the case shall contact the other contractor PI unit for exposure.
The initiating contractor PI unit shall provide the other contractor
PI unit with the fraud/abuse scheme, name of provider (s) to include
practice name, Tax Identification Numbers (TINs), National Provider
Identifier (NPI), or National Council of Prescription Drug Program
(NCPDP) provider Identification and date range so research may be
conducted. DHA PI shall be informed in the case report of these
contacts and findings if suspected practice is a pattern among national
or regional chains. Findings of potential fraud or abuse by another
contractor shall be reported to DHA PI by the contractor who initiated
the investigation.
3.1.2 In any
situation which could lead to duplicate investigative efforts, the
contractors involved must notify DHA PI for the proper coordination.
Joint case referrals shall be submitted by the contractor that initiated
the case first. Each contractor with exposure will conduct an independent
audit; however, all findings shall be submitted by the initiating
contractor PI unit.
3.1.3 Those
issues that cannot be resolved at the operational level between
the contractors shall be elevated to DHA PI for resolution.
3.2 Contractor Coordination And
Support With DOJ, USAO, And Investigative Agencies
3.2.1 Requests
for health care fraud and abuse information by DOJ and DCIS must
be referred to DHA PI. Contractor contact by any investigative agency,
e.g., FBI, MCIOs, etc., shall also be reported immediately to DHA
PI. The contractor may not release any documents or copies of documents, conduct
audits, etc., at the request of any individual or agency without
direction from DHA PI. (This includes requests from all other entities,
including anti-fraud associations). If the contractor responds directly
to a request for documentation from an investigative agency or other
entity, the costs of responding shall not be charged to the contract.
3.2.2 It is DoD policy that all employees,
contractors and subcontractors shall cooperate fully with investigative
agencies of the U.S. upon the direction of DHA PI. All requests
for claims histories, medical and other records, regulatory/manual
provisions, correspondence, audits and other documentation (e.g.,
newsletters, claims, checks, etc.) shall be provided by the contractor.
Requests for witnesses and technical support will be completed by
the contractor regardless of the time frames or dates of service
identified in the request should this cross contractor jurisdiction
or involve legacy contracts.