TriCare Cracking Down on Healthcare Fraud and Abuse

Providers servicing military populations and accepting TriCare should be wary: TriCare and the Department of Justice are ramping up efforts to crack down on TriCare fraud and abuse.

Providers in Florida, Hawaii, Texas, North Carolina, California, and other states with heavy military populations will see increased scrutiny by the Department of Justice, Defense Criminal Investigative Service, and the FBI for improper billing of TriCare services.

In 2017, Attorney General Jeff Sessions announced the largest healthcare fraud takedown in U.S. history: 412 individual defendants were indicted for unlawfully submitting $1.3 billion in fraudulent claims. These claims include Medicaid fraud, Medicare fraud, and TriCare for treatments that weren’t rendered, not medically necessary, or improperly billed. Many of those cases were related to physicians and pharmacies who improperly billed TriCare for services that were not rendered.

While TriCare fraud cases were previously limited mostly to compounding pharmacy cases. The investigations have recently expanded into occupational therapy, speech therapy, physical therapy, and other outpatient services.

When a provider submits a bill to TriCare , that provider is certifying that it has complied with all of TriCare’s rules and regulations contained in its TriCare provider manual. This includes rules related to reimbursement, coding, and credentialing. Failure to abide by the TriCare provider manual, according to the government, can equate to TriCare fraud.

You may be charged for health care fraud under 18 U.S.C. 1347, which is a federal criminal statute. The providers who are accused of TriCare fraud can also be charged with wire fraud, making false statements related to healthcare, even RICO (an organized crime statute).