TRICARE Takes on Fraud in the U.S., Maybe!

In an amazing turn-a-round TRICARE has now decided to go after a share of the $80 billion fraud industry in the United States! See TRICARE Urges Beneficiaries to Keep Alert for Signs of Fraud & Abuse.

For ten years the former TRICARE Management Activity (TMA), now the Defense Health Agency (DHA) deliberately ignored fraud in the Philippines, allowing a company conceived and operated by an American, to grow and prosper using fraud against TMA, the American taxpayer and TRICARE beneficiaries as the basis for massive profits. Only when threatened by the DODIG and Congress did they finally take action. But the action included claims that beneficiaries were behind much of the fraud claiming, among other things, if beneficiaries had refused to use the defrauder, that TMA ignored for ten years and paid without question, there would have been no fraud for TMA to fight. This was the start of what many would call ‘The War on Beneficiaries’ in the Philippines.

While they were waging this war TMA conveniently ignored massive fraud in their own back yard. They knowingly allowed physicians to be certified as tertiary hospitals and paid them tens of thousands of dollars for care they never provided. They knowingly allowed businessmen to be certified as physician groups and for a fee trained to defraud and then allowed hundreds of legitimate providers to be improperly certified as working at these fake physician groups to assist in increased profits for the defrauders and their co-conspirators alike.

Instead of seeking out the true defrauders behind these scams TMA chose to lay the blame on local providers and beneficiaries. Many providers were duped into thinking what they were doing was correct and legitimate by what they saw as the local representative of TRICARE. Further they chose to try to pass the blame on to beneficiaries in a war that included large doses of propaganda. For example making claims to Congress that essentially 64% of providers and 77% of beneficiaries are on prepayment review for suspected fraud while saying something entirely different to others.

The claims of fraud by providers included:

· Billing for the cost of non-covered or non-chargeable services. (Billing a patient for services not covered by TRICARE or other insurance plan would not usually be considered a crime by anyone else in the world.)

· Unbundling (or fragmented) billing. (The crime here is that local providers failed to modify their local billing practices to match the complex and unique U.S. system because TMA wanted them to.)

· Charging beneficiaries rates for services/supplies in excess of those in locale.

· Billing substantially in excess of customary and reasonable charges. (These two are classic since these claims of fraud went on for many years until their contractor advised providers to increase rates for TRICARE patients under the Demo, at which time it became an acceptable practice.)

· Billing an office visit for prescription refill only. (While this may be considered fraud in the states, it is the normal ‘standard of practice’ in the Philippines and TMA’s own Operations Manual states that local standards of practice are to be considered for overseas claims. But since they have nobody on the ground they haven’t a clue so scream fraud.)

The above charges of fraud obtained from a Program Integrity brief.

We, as beneficiaries, are still vilified and chastised by DHA for the ‘suspected’ fraud we constantly commit. But they are finding their ‘mining’ for ‘fraud cost avoidance’ savings through denial of legitimate claims is drying up. More and more beneficiaries no longer bother to file claims to a system that is designed to deny them to increase these claimed fraud savings.

A glaring difference in their war on fraud in the states and here is they are not publicly accusing U.S. TRICARE beneficiaries of being ultimately responsible for the fraud they become involved in like they do here. They also haven’t placed their ‘magic’ statistical numbers on them and providers yet, such as 64% of all U.S. providers and 77% of all U.S. beneficiaries are on prepayment review due to ‘rampant’ fraud in the U.S. But we should give them time, they tried it here and it worked to alienate Congress and some VSOs so they could operate without scrutiny.

Or maybe that’s because more professional groups such as the FBI, various IGs, the IRS and others go after the defrauders instead of the less professional ones contracted for that prefer to claim millions of Philippine beneficiaries tried to file claims with a medical insurance plan for house damage. Many would call this putting the fox in the henhouse to guard the chickens.

But hey guys – Never forget the Defense Health Agency and International SOS always have your back when it comes to high quality and easy access to care; just ask them!