Understanding Fraud & Abuse

<h2>UNDERSTANDING FRAUD AND ABUSE</h2> {marginbottom=24: } <h4>{nomargin: What is Fraud and Abuse?}</h4> Fraud is the intentional deception or misrepresentation that an individual knows to be false, when that individual knows the deception could result in some unauthorized benefit or payment. {marginbottom=15:Abuse involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices. ‎ Abuse directly or indirectly results in unnecessary costs to the program through improper payments, or in reimbursement of services that are not medically necessary or fail to meet professionally recognized standards of health care.} <h4>{lineheight=1;nomargin:Health Care Program Integrity: Background Information}</h4> {marginbottom=32: } A study conducted by the European Healthcare Fraud and Corruption Network (EHFCN) in conjunction with the Center for Counter Fraud Services (CCFS) estimates approximately 5.59% of annual health care spending across the globe is lost to fraud and/or administrative error. {nomargin: } Fraud has an effect on everyone in the health care system. ‎ As a result, beneficiaries may be subject to higher cost shares and premiums as well as unnecessary and possibly dangerous medical services and treatments, which can have devastating consequences.  International SOS and the TOP Claims Processor’s Program Integrity teams actively work with the Defense Health Agency to identify, investigate, and cease abusive and fraudulent activities in an effort to protect beneficiaries, the TRICARE benefit, and taxpayers, leading to cost savings worth millions of dollars annually.  {fontweight=500;nomargin: Examples of Fraud/Abuse:} {nomargin: • Providers billing for medical services not provided (e.g., reported on your Explanation of Benefits)} {nomargin: • Providers routinely waiving beneficiary cost shares} {nomargin: • Medical/health insurance identity theft}  {nomargin: • Providers billing for more expensive services than performed, i.e., up-coding of more comprehensive services than received, as reported on your Explanation of Benefits} {nomargin: • Providers performing (or beneficiaries receiving) medically unnecessary services solely for the purpose of reimbursement} {nomargin: • Providers billing and masking non-covered services as other covered services for reimbursement (e.g., cosmetic procedures not covered being billed as medically necessary)} {nomargin: • Falsifying/altering medical claims} {nomargin: • Providers billing for all authorized services prior to beneficiary receiving them} {nomargin: • Falsifying/altering medical diagnosis to justify unnecessary services/treatments} {nomargin: • Overutilization of services} {nomargin: • Providers billing for the same services on the same date of service more than once} {nomargin: • Anyone other than your physician filling out a certificate of medical necessity form} {marginbottom=-7;normagin:} <h4>{nomargin:What is Identity Theft?}</h4> {marginbottom=24;nomargin:} Beneficiaries should be vigilant of who has access to their TRICARE identification card. ‎Even more important overseas, it is very common for beneficiaries to receive original copies of their medical records, making it imperative to protect this information from getting into the hands of an individual who may use it to commit fraud.{nomargin: } The following are examples of how beneficiary information can be used fraudulently:{nomargin: } {nomargin: • Purchasing beneficiary information for the sole purpose of committing fraud.} {nomargin: • Attending no-cost medical fairs, where personal medical information is collected.} {nomargin: • Medical records getting into the wrong hands and being copied or used to submit fraudulent claims; this will result in inconsistent medical histories and can also have a potentially devastating effect personally. } <h4>{fontweight=400:How Can You Protect Yourself?}</h4> {nomargin: • Always safeguard your TRICARE benefit identification card and keep all medical records in a safe place.} {nomargin: • Always be vigilant of anyone trying to obtain your medical information, such as “free” services requiring you to provide your health care insurance information. } {nomargin: • Know your medical provider! Do your research to ensure your medical well-being is in the hands of a reputable provider who has only YOUR health in mind.} {nomargin: } • Read and understand your TRICARE Explanation of Benefits (EOB). If you have questions always ask for help.  ‎Contact your {contentlink=/contact-us:TOP Regional Call Center} anytime (listen carefully to the prompts for the best option to serve you) for TOP Claims Assistance or with any questions regarding your EOB. Your EOB contains information reported by your medical provider; any inconsistencies may be reflected on the EOB. {nomargin: • Always report any activity that may appear suspicious! The best defense against fraud and abuse are the beneficiaries who report it. } {nomargin: • If you are not sure if the treatment/tests/procedures your provider has ordered are necessary for your condition, it’s OK to question your provider. You are your own best health care advocate.} {marginbottom=36: } <h4>{nomargin:Reporting Fraud and Abuse:}</h4> {marginbottom=24: } Please report, anonymously or by name, any suspected fraudulent or abusive behavior by beneficiaries or providers using one of the following options: <table style="width: 713px; font-weight: bold;"> <tbody> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">Call the Fraud Tip Hotline:  </td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;">Toll-free: +1-877-342-2503 Direct: +1-215-354-5020 </td> </tr> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">Fax correspondence to: </td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;">+1-215-354-2395 </td> </tr> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">Send an email to: </td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;"><a href="mailto:TOPProgramIntegrity@internationalsos.com" style="font-weight: lighter; color: rgb(0, 119, 204); font-size: inherit;" target="_blank">TOPProgramIntegrity@internationalsos.com</a> </td> </tr> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">Mail correspondence to: </td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;">ATTN: TRICARE Program Integrity 1717 W. Broadway P.O. Box 7635 Madison, Wisconsin 53707 USA</td> </tr> </tbody> </table> Please provide as much information as possible to assist in the investigation. Any information you provide will remain strictly confidential.  * Note: It is current International SOS’ Fraud Hotline policy not to respond directly to written communications.

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