TRICARE Manuals - Display Chap 13 Sect 4 (Change 138, May 21, 2024)

Program Integrity

Chapter 13

Section 4

Reports

Revision:

1.0 Fraud And Abuse Summary Report

The Fraud and Abuse Summary Report shall be compiled and submitted to the Defense Health Agency (DHA) Program Integrity Office (PI) within 30 calendar days following the last day of each calendar quarter. The corresponding Contract Data Requirements List (CDRL), DD Form 1423 provides details on the contents and submission of this report.

2.0 Pi Cost Avoidance And Recovery/Recoupments

2.1 The contractor shall report to DHA PI the cost avoidance and recoveries/recoupments achieved as a result of the activities/intervention of the anti-fraud investigative unit and other units contributing to health care fraud detection/prevention. This report shall be submitted to DHA PI within 30 calendar days following the last day of the quarter.

2.2 PI Cost Avoidance and Recovery/Recoupments Report shall provide information detailing:

• Cost Avoidance, Recoveries, and Recoupments; along with the cost associated with all Program Integrity (PI) activities.

• Return on Investment (ROI): calculated by utilizing the DHA PI ROI tables provided on the quarterly report. Table requires utilizing aggregate labor, sub-contracting, overhead administrative, technology, travel/training and other miscellaneous costs associated with PI to be maintained by contractor.

• Information from the DMDC Claims Reprocessing Report which results in eligibility reviews, recoupments initiated, collected, or transferred to DHA.

• A variance analysis for any reporting category with a 15% increase or decrease from the current quarterly report to the last quarterly report, to include any unusual activity even if it does not exceed the percentage. Provide a summary analysis to be included in the fourth quarter Fraud and Abuse Summary Report to reflect unusual activity that persists throughout all four quarters.

3.0 Utilization Report

A utilization report shall be generated and included as an addendum to the Fraud and Abuse Summary Report. This report shall include a brief description of the software listing the analytical techniques used for fraud detection, a Utilization Rate for the use of this software for both pre-pay and post-pay claims, a ROI of the software (the savings generated by the software versus the costs), and the rate or impact of False Positives to fraud detection through the use of the software. An aggregate listing of the potential cases that were identified as a result of the use the software shall also be included. This is in addition to cases being developed under other methods, i.e., receipt of beneficiary complaints, law enforcement inquiries, other private plan referrals, etc. This utilization report and aggregate list of cases and their disposition shall be included as an addendum to the Fraud and Abuse Summary Report. In addition, provide total number of unique balance billing matters and violation of participation agreement matters resolved during calendar year as an addendum to the fourth quarter Fraud and Abuse Summary Report.

Note: These balance billing numbers and violation of participation numbers may be added to the fourth quarter Summary Report as footnotes.

4.0 Predictive Analytics/Modeling Metrics Report

4.1 Predictive Analytics/Modeling Software Metrics-Prepay

Contractor shall report on a quarterly basis key metrics covering the use and results of the predictive analytics/modeling software, as it was used prepay (before claims are paid). This requirement is specific to the predictive analytics/modeling software described in Chapter 13, Section 1, paragraph 1.3, and is separate from the use and results of expert or rules based software. The quarterly prepay metrics to be reported include a description of the personnel level of effort using the software prepay, the number of man hours spent using the software prepay, the cost of the prepay software, and the total prepay cost of avoidance attributed to the software.

4.2 Predictive Analytics/Modeling Software Metrics - Post-Pay

Contractor shall report on a quarterly basis key metrics covering the use and results of the predictive analytics/modeling software, as it was used post-pay (after claims are paid). This requirement is specific to the predictive analytics/modeling software as described in Chapter 13, Section 1, paragraph 1.3, and is separate from the use and results of expert or rules based software. The quarterly post-pay metrics to be reported include a description of the personnel level of effort using the software post-pay, the number of man hours spent using the software post-pay, the cost of the post-pay software, and the total post-pay cost of avoidance attributed to the software. The corresponding CDRL, DD Form 1423 provides details on the contents and submission of these reports.

5.0 Threats

The contractor shall immediately report all threats to the local police authorities. A written report shall be completed by the individual receiving the threat and sent to the DHA PI Chief of Investigations Oversight for information referral to the Defense Criminal Investigative Service (DCIS) office having jurisdiction over the area where the threat was initiated or act was stated to occur. This includes all threats against person or property. The contractor shall provide a report of the threat to DHA PI giving as much information as possible, within five working days of the threat.

6.0 All reports generated as a result of this section or any other section of Chapter 13, shall include the following statement at the bottom of each page.

The recipients of this report are hereby advised that it contains information that is “Law Enforcement Sensitive” or “For Official Use Only”. Disclosure to unauthorized sources is strictly prohibited.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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