TRlCARE Controls Over Claims Prepared by Third-Party Billing Agencies
Abstract
In 2006, we reported on controls over TRICARE payments made to overseas health care providers. We identified a billing agency in the Philippines that submitted false claims and was eventually convicted by the U.S. Attorney's Office for receiving fraudulent payments totaling about $100 million. We performed this audit to determine whether similar weaknesses existed within TRICARE in the United States. Centers for Medicare and Medicaid and Department of Health and Human Services have identified problems with billing agencies in the United States and have developed regulations to deter future fraud by these agencies. The objective of the audit was to evaluate the adequacy of TRICARE controls over payments for health care claims prepared by billing agencies for care provided in the United States. The TRICARE Management Activity needs to improve controls over payments for health care claims prepared by billing agencies for care provided in the United States. Contrary to the Federal regulations and the TRICARE Operations Manual, the TRICARE Management Activity sent payments to billing agencies rather than to providers and also paid claims prepared by billing agencies that were excluded by the Department of Health and Human Services from participating in Federal health care programs. The TRICARE Management Activity made these payments because it did not identify relationships between providers and billing agencies, and when sending payments, it used the billing agency s address instead of the provider s address. Further, TRICARE Management Activity officials believed they lack the authority to exclude billing agencies that are involved in preparing or submitting improper health care claims.
Document Details
- Document Type
- Technical Report
- Publication Date
- Dec 31, 2008
- Accession Number
- ADA596244
Entities
Organizations
- Office of the Inspector General, U.S. Department of Defense