Understanding Fraud and Abuse

<h4>What is Fraud and Abuse?</h4> <p>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.</p> <p>Abuse involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices.&nbsp;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.&nbsp;&nbsp;</p> <p>International SOS, the TRICARE Overseas Program (TOP) contractor, is committed to detecting, correcting, and preventing health care fraud and abuse. Fraud happens when a person or organization takes action to deliberately deceive others to gain an unauthorized benefit. Health care abuse occurs when Providers supply services or products that are medically unnecessary or that do not meet professional standards.</p> <p>The health care profession (both stateside and overseas) is marked by honest, compassionate, ethical Providers. As with all industries however, the health care field also has individuals and institutions who conduct dishonest practices that can be harmful to beneficiaries and the medical community as a whole. Health care fraud and abuse can result in serious criminal investigation and prosecution.&nbsp;</p> <p><u>Examples of Fraud/Abuse:</u>{nomargin:}</p> <p>• Billing for medical services not provided{nomargin:}&nbsp;</p> <p>• Routinely waiving beneficiary cost shares{nomargin:}&nbsp;</p> <p>• Billing for more expensive services than performed, up-coding{nomargin:}&nbsp;</p> <p>• Performing medically unnecessary services solely for the purpose of reimbursement{nomargin:}&nbsp;</p> <p>• Billing and masking non-covered services as other covered services for reimbursement{nomargin:}&nbsp;</p> <p>• Falsifying/altering medical claims{nomargin:}&nbsp;&nbsp;</p> <p>• Overutilization of services{nomargin:}&nbsp;</p> <p>• Billing for all authorized services prior to services being rendered{nomargin:}&nbsp;&nbsp;</p> <p>• Falsifying/altering medical diagnosis to justify unnecessary services/treatments{nomargin:}&nbsp;</p> <p>• Billing for the same services on the same date of service more than once&nbsp;</p> <h4>Reporting Fraud and Abuse:</h4> <p>Please report, anonymously or by name, any suspected fraudulent or abusive behavior by beneficiaries or providers using one of the following options:</p> <table style="width: 713px;"> <tbody> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">Call the Fraud Tip Hotline:&nbsp;</td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;">Toll-free: +1-877-342-2503<br>Direct: +1-215-354-5020&nbsp;</td> </tr> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">&nbsp;Fax correspondence to:<br></td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;">+1-215-354-2395<br></td> </tr> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">&nbsp;Send an email to:<br></td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;"><a href="mailto:TOPProgramIntegrity@internationalsos.com" style="color: rgb(0, 119, 204); font-size: inherit;" target="_blank">TOPProgramIntegrity@internationalsos.com</a><br></td> </tr> <tr> <td colspan="1" rowspan="1" style="border-width: 1px 1px 1px 0px; font-size: 0.875rem;">&nbsp;Mail correspondence to:<br></td> <td colspan="1" rowspan="1" style="border-width: 1px 0px 1px 1px; font-size: 0.875rem;">ATTN: TRICARE Program Integrity<br>1717 W. Broadway<br>P.O. Box 7635<br>Madison, Wisconsin 53707<br>USA<br></td> </tr> </tbody> </table> <p>Please provide as much information as possible to assist in the investigation. Any information you provide will remain strictly confidential.&nbsp;</p> <p><i>* Note: It is current International SOS’ Fraud Hotline policy not to respond directly to written communications.</i></p>