1.0 CONTRACTOR'S PROGRAM INTEGRITY
(PI) RESPONSIBILITY
1.1 The contractor
shall establish and operate a dedicated TRICARE PI function.
1.1.1 The contractor shall ensure
that medically necessary medical, pharmacy, and dental services
are provided to only eligible beneficiaries by authorized providers
or reimbursement made to eligible beneficiaries or providers under
existing law, regulation and Defense Health Agency (DHA) instructions.
1.1.2 The contractor
shall develop and implement a corporate strategy that is committed
to health care fraud prevention and detection in the TRICARE program.
The strategy shall include processes focused on health care fraud
awareness, education, processes to identify health care fraud, correction,
prevention, referral of health care fraud cases, prosecutorial support,
and deterrence of health care fraud.
1.1.3 The contractor
shall perform an annual fraud and abuse risk assessment to determine
areas of vulnerability, high risk areas, specific fraud and abuse
schemes, significance of risks, and mitigation measures within the
scope of contract.
1.1.4 The contractor shall identify
and implement cost-containment strategies and anti-fraud strategies
to combat and prevent unnecessary spending that supports medically
necessary and appropriate care in the TRICARE program.
1.1.5 The contractor
shall submit a comprehensive PI plan that addresses the elements
of
paragraph 1.1. For plan submission requirements,
see DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract.
1.2 Use of Predictive Analytics
and Anti-Fraud Software Requirements
1.2.1 The contractor
shall perform analyses of non-institutional and institutional health
care data associated with type, frequency, duration and extent of
services with the intent of identifying patterns of fraudulent or
abusive practices and behaviors by providers or beneficiaries on
a prepayment (before claim is paid) and post-payment (after claim
is paid) basis for the purposes of fraud prevention and detection.
1.2.2 The contractor
shall obtain and utilize predictive analytics software. The anti-fraud
software program(s) shall have predictive capabilities defined as
the application of statistical models to assign probabilities and
risk scores and detect fraudulent, abusive, and aberrant activities.
1.2.3 The contractor’s
PI software components shall employ a variety of statistical modeling
components and a wide range of analytic techniques and include but
not be limited to predictive analytics and modeling, descriptive
statistics, rules based analysis, predictive algorithms, trend analysis,
and geographic clusters.
1.2.4 In order to be considered predictive,
the software shall not be limited to only expert or rules based logic,
and include more advanced analytical techniques such as artificial
intelligence, machine learning, and regression techniques to flag
providers for further evaluation.
1.2.5 The contractor’s
PI software shall assign predictive risk scores to claims on a prepayment
basis to evaluate the accrual of the new claims in aggregate with
previously submitted claims in a pattern of fraud, abuse, or billing
error. Relationships between providers shall be evaluated post-payment
(flagged with flagged, flagged with non-flagged).
1.2.6 The contractor
shall have trained staff to review and track providers flagged by
the PI software on a daily basis.
1.2.7 The contractor
shall use the results of this software to implement timely actions
to prevent any further “suspect” claims and prevention of any further
“suspect” claims. This paragraph is not applicable to the TRICARE Medicare
Eligible Program (TMEP).
1.2.8 The contractor shall utilize
predictive analytics software to utilize prepayment edits that specifically identify
potential fraud and abuse.
1.2.9 The contractor’s
software shall have reporting capability to produce comprehensive
fraud detection reports and metrics to include reporting cost avoidance
and cost savings.
1.2.10 The contractor shall augment
and update software program accordingly to incorporate analytic approaches
not mentioned, or, to leverage new statistical techniques or new
applications of existing techniques.
1.2.11 The contractor shall report
the results from the use of this software, both prepayment and post-payment
results. For reporting requirements, see DD Form 1423, CDRL, located
in Section J of the applicable contract.
1.3 Predictive
Analytics And Modeling Metrics Report
1.3.1 The contractor
shall report on a quarterly basis the key metrics covering the use
and results of the predictive analytics and modeling software, as
it was used prepayment (before claims are paid) and post-payment (after
claims are paid) and report on actions taken from leads generated
from use of software (e.g., prepayment, education). This requirement
is specific to the predictive analytics and modeling software described
in
paragraph 1.2.
1.3.2 The contractor
shall include the following statement at the bottom of each page
for all reports generated as a results of this section or any other
section in this chapter.
“The recipients of this report
are hereby advised that it contains information that is Law Enforcement
Sensitive”.
1.4 Anti-Fraud
and Abuse Support
1.4.1 The contractor shall provide
technical and professional consultation, support, and information
to DHA PI to include but not limited to investigating and prosecuting
support, submission, adjudication and reimbursement of claims for
health care services, pharmacy or dental services.
• Delivery of health care services
in the 50 United States (US) and the District of Columbia and outside
the 50 US and the District of Columbia.
• Submission, adjudication and
reimbursement of claims for health care services, pharmacy or dental
services.
• TRICARE operations and benefits.
• Anti-fraud and Abuse activities.
1.4.2 The contractor
shall:
1.4.2.1 Provide investigating and prosecuting
support to include documents, reports, correspondence, audits, and
other applicable data or items as requested.
1.4.2.2 Provide documents, reports,
correspondence, claims data, and other applicable data or items
in support of compliance monitoring, oversight activities, oversight
monitoring, or other PI related issues.
1.4.2.3 Provide documents, reports,
correspondence, claims data, and other applicable data or items
in support of contractor actions.
1.4.2.4 Provide specific data and supporting
documentation required during development and investigative process
(i.e., initiated by contractor, law enforcement, Department of Justice
(DOJ), or DHA PI).
1.4.3 At DHA
PI’s request, identify and provide expert(s) or program witness(es)
at Grand Jury hearings, criminal trials, civil hearings, depositions,
and administrative hearings.
• 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.
1.4.4 Provide
claims data and supporting documentation customary electronic format
and media compliant with the Health Insurance Portability and Accountability
Act (HIPAA).
1.4.4.1 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 and findings, or any other relevant
information as requested (e.g., documents from other offices and
units).
1.4.4.2 Have dedicated personnel and
resources available to meet the timeliness requirement as directed
by DHA PI for retrieval, transmission, and mailing of the information.
1.4.5 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)).
1.4.6 Comply with the Alcohol, Drug
Abuse and Mental Health Administration (ADAMHA) Reorganization Act,
Public Law 102-321 (July 10, 1992) and implementing regulations
including 42 Code of Federal Regulations (CFR) Part
2, when data requested includes services related to substance abuse
or mental health.
1.4.7 The contractor shall develop,
maintain and follow standard operating procedures related to requirements
and activities within this chapter (e.g., desk procedures).
1.4.8 The contractor
shall provide a copy, in electronic read-only format to DHA PI at
the start of the contract with updates provided as changes occur.
For reporting requirements, see DD Form 1423, CDRL, located in Section
J of the applicable contract.
2.0 FRAUD AND ABUSE TRAINING AND
EDUCATION
2.1 The contractor shall establish
and maintain a formal training program for all contractor personnel
in the prevention, detection, and reporting of potential fraud or
abuse situations.
2.2 The contractor shall include
fraud and abuse as a specific segment of its regular training programs
and also include TRICARE specific information (refer to
Chapter 1, Section 4).
2.3 The contractor shall provide
training program material to DHA PI upon request.
2.4 PI
Staff Education
2.4.1 The contractor shall ensure
that all PI staff have adequate TRICARE and industry fraud and abuse training,
education, and experience to perform TRICARE PI functions.
2.4.2 The contractor
shall provide desk procedures to the staff which include methods
for control of claims and encounters exhibiting unusual patterns
of care, over or under utilization of services, or other practices
which may indicate fraud or abuse.
2.4.3 The contractor
shall include specific criteria for referral of cases to professional
or supervisory review concerning issues with patterns of care, abnormal
utilization practices, or suspect billing practices.
2.4.4 The contractor
shall establish and maintain an ongoing anti-fraud and abuse education
program addressed to beneficiaries, providers, and pharmacies. The
education program shall provide information about identified fraudulent
or abusive practices, and how individuals may identify and report
such practices.
2.4.4.1 The contractor shall include
information reminding providers seeking payment from the TRICARE program
have a duty to familiarize themselves with, and to comply with program
requirements.
2.4.4.2 The contractor shall accomplish
this by including information in the provider quarterly newsletter, provider
handbooks, email, World Wide Web (WWW), and other social media and
by periodic notices on the electronic explanation of benefits and
provider remittance advice.
2.4.4.3 The contractor shall provide
copies of newsletters and notices to DHA PI upon request.
3.0 FRAUD
AND ABUSE REPORTING MECHANISMS
3.1 The contractor shall have Fraud
and Abuse reporting mechanisms available to beneficiaries, providers, and
concerned parties to report suspected fraud and abuse.
3.2 The contractor
shall have the ability to report fraud or abuse that are secure
and HIPAA compliant by telephone, email, fax, secure online submission,
and mail.
3.3 The contractor shall include
anonymous and non-anonymous options (e.g., fraud hotline, email,
fax, mail) for reporting also.
4.0 FEDERAL
AGENCIES ROLES AND RESPONSIBILITIES (INFORMATIONAL)
4.1 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.
4.2 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 and state agencies.
4.3 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 also coordinates with DHA PI for actions pursued under the
Program Fraud Civil Remedies Act (PFCRA), and initiating administrative
measures. Settlements that affect the agency (e.g., civil settlement,
a provider’s or pharmacy’s TRICARE status, sanctions) are coordinated
with and approved by a DHA representative.
4.4 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.
4.5 Defense
Criminal Investigative Service (DCIS) Of The DoDIG
DCIS is responsible for all
fraud and 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 and 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).
4.6 Military
Criminal Investigation Organizations (MCIOs)
The MCIOs include the United
States Army Criminal Investigative Division (USACID), Naval Criminal
Investigative Service (NCIS), United States (US) Air Force Office
of Special Investigations (AFOSI), US 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.
4.7 Defense Contract Audit Agency
(DCAA)
Upon request,
the DCAA provides audit assistance to DHA, DCIS and MCIOs.
4.8 DOJ
And US 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 US DOJ has jurisdiction for Federal criminal
and civil action.
4.9 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.
5.0 EXTERNAL
CONTRACTOR COORDINATION AND SUPPORT WITH DOJ, USAO, AND INVESTIGATIVE AGENCIES
5.1 The contractor
shall not provide any information to external investigative agencies
or any other entity without prior approval and coordination from
DHA PI.
5.2 The contractor shall notify
DHA PI when a contractor is contacted directly by any investigative
or external agency (e.g., FBI, MCIOS, DCIS).
5.3 The contractor
shall not release any documents (e.g., copies of document, audits)
at the request of an individual or agency without direction DHA
PI. This includes requests from all other entities, including anti-fraud associations.
5.4 It is
DoD policy that all employees, contractors and subcontractors cooperate
fully with investigative agencies of the US upon the direction of
DHA PI.
5.5 The contractor shall provide
all requests for claims histories, medical and other records, regulatory
and manual provisions, correspondence, audits and other documentation
(e.g., newsletters, claims, checks).
5.6 The contractor
shall complete all requests for witnesses and technical support
regardless of the time frames or dates of service identified in
the request should this cross contractor jurisdiction or involve
legacy contracts.
6.0 REPORTING
The contractor shall have reporting
requirements that are compiled and submitted to DHA PI. For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
6.1 Fraud
And Abuse Summary Report
The Fraud and Abuse Summary
Report shall be compiled and submitted to the DHA PI within 30 calendar
days following the last calendar day of each calendar quarter.
6.2 PI
Cost Avoidance And Recoupments
6.2.1 The contractor shall report
to DHA PI the cost avoidance and recoupments achieved as a result
of the activities, initiation, and involvement of the anti-fraud
investigative unit and other units contributing to health care fraud
detection, prevention, and deterrence.
6.2.2 The contractor
shall provide information detailing:
6.2.2.1 Cost avoidance, recoveries,
and recoupments; along with the cost associated with all PI activities.
6.2.2.2 Return on Investment (ROI):
calculated by utilizing the DHA PI ROI tables provided on the quarterly report.
Table requires utilizing aggregate labor, subcontracting, overhead
administrative, technology, travel, training, and other miscellaneous
costs associated with PI to be maintained by contractor.
6.2.2.3 Summarize all actions taken
during reporting period to ensure timely action.
6.2.2.4 Information from the DMDC Claims
Reprocessing Report which results in eligibility reviews, recoupments
initiated, collected, or transferred to DHA.
6.2.2.5 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,
and includes a year to year variance comparison for all periods
of the contract. For reporting requirements, see DD Form 1423, CDRL,
located in Section J of the applicable contract.