Fraud and Abuse: How Does It Affect TRICARE Beneficiaries? (East Region)

This article contains information specific to beneficiaries living in the East Region. Check the map to find your region.

Healthcare fraud isn’t a victimless crime. Medical fraud can raise costs and expose patients to unnecessary medical tests. If you suspect that a TRICARE provider has committed fraud or abuse, you may report this suspicion to Humana Military.

Fraud happens when a person or organization deliberately deceives others to gain some sort of unauthorized benefit.

Abuse occurs when providers supply services or products that aren’t medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. or that don’t meet professional standards.

Here are some easy ways to keep an eye out for fraud or abuse related to your benefits, claims, and bills.

• Review your explanation of benefits and medical bills to make sure that the services billed were performed by the provider listed and on the date specified.
• Keep track of every bill that TRICARE received or paid. This way you can see if you received a bill more than once for the same service. Don’t be afraid to ask your provider about the necessity of each test, lab, or procedure — especially if it seems excessive.
• Don’t accept discounts, such as on medical payments or the waiver of your copaymentA fixed dollar amount you may pay for a covered health care service or drug.. Your bill must reflect any discounted amount.
• If you have questions about a bill, contact the provider.

Sometimes it can be difficult to know what health care fraud looks like. Here are some top examples.

• Billing for services, supplies, or equipment not rendered
• Misrepresenting the dates of service, the provider, or the location of the service
• Billing excessive units
• Reporting an incorrect diagnosis or procedure code
• Billing for a non-covered service
• Waiving beneficiary deductibles or copayments
• Overutilization of services
• Billing for medically unnecessary services
• Charging a beneficiary more than their cost-shareA percentage of the total cost of a covered health care service that you pay.
• Duplicate billings
• Kickbacks and bribery
• Conflicts of interest

Humana Military investigates all claims of fraud and abuse. Humana Military wants to determine whether there is enough evidence to report the case to the government for further investigation. When submitting a report, you may remain anonymous. You can make a report by phone at 800-333-1620.