Defense Health Care: Improvements Needed to Reduce Vulnerability to Fraud and Abuse
Abstract
The mission of the military health care system is to maintain the health of active duty service personnel and provide health care during military operations. The system also offers health care to non-active duty beneficiaries, including dependents of active duty personnel and military retirees and their dependents, through various military-operated hospitals and clinics worldwide; the system is supplemented through contracts with civilian health care providers. TRICARE, the name given to the program providing this care, is a triple-option benefit program designed to give beneficiaries a choice among a health maintenance organization, a preferred provider organization, and a fee-for-service benefit. Five managed care support contractors create networks of civilian health care providers. These providers submit claims, either individually or as part of a group practice, to contractors for payment of medical care they have provided to DOD beneficiaries. Fraud occurs when health care providers knowingly submit claims containing false information. Common types of provider fraud and abuse include billing for services not rendered, misrepresentation of services, and conducting unwarranted medical procedures. Multiple players support DOD's health care fraud identification and prevention efforts. DOD's TRICARE Management Activity's(TMA)Program Integrity Branch serves as the centralized administrative hub for TRICARE fraud and abuse activity worldwide. Its primary responsibilities include (1) developing policies and procedures for the prevention, detection, investigation, and control of TRICARE fraud and abuse; (2) educating beneficiaries, health care providers, and others about various health care fraud and abuse issues; (3) initiating administrative remedies, such as sanctioning fraudulent providers; and (4) coordinating with other DOD and external investigative agencies, such as the Federal Bureau of Investigation, to assist in investigations of health care fraud and abuse.
Document Details
- Document Type
- Technical Report
- Publication Date
- Jul 01, 1999
- Accession Number
- AD1177172
Entities
People
- Stephen P. Backhus
Organizations
- United States Government Accountability Office