TRICARE Audit Defense Attorneys

What Providers Need to Know About TRICARE Audits

TRICARE is a healthcare program for active and retired uniformed service members and their families. TRICARE provides worldwide healthcare coverage, including health plans, dental plans, prescriptions, and special programs.

As a TRICARE-authorized civilian provider, your business or practice supplements the healthcare resources provided through military hospitals and clinics.

How Is TRICARE Managed?

The U.S. Military Health System contracts with managed care support contractors (MCSC) to administer TRICARE health plans in each of three regions:

  • East is managed by Humana Military
  • West is managed by Health Net Federal Services
  • Overseas is managed by International SOS

Express Scripts is the online pharmacy and pharmacy benefit manager for TRICARE. United Concordia administers the TRICARE Dental Plan.

Each of these contractors must maintain a dedicated Program Integrity Department and a Special Investigations Unit to flag and audit suspected fraud. Providers under review may receive a letter from an MCSC, or their case may be referred to a federal or state law enforcement agency for investigation.

TRICARE Fraud Investigations

Hendershot Cowart P.C. has extensive experience representing clients who have received Civil Investigation Demand (CID) letters or subpoenas in connection to alleged TRICARE fraud, or who have been made aware of TRICARE audit or investigation by a TRICARE contractor.

Because the federal government is prioritizing these investigations, and because they create substantial risks for prosecution and penalties, including civil and criminal liability, early intervention by an attorney is of the utmost importance.

Our legal team responds immediately to TRICARE fraud investigations to communicate with authorities, interpret and respond appropriately to CIDs and other government demands, and to explore options for resolutions, including various defense strategies against allegations that focus on:

  • Lack of medical necessity / doctor-patient relationships – Federal authorities have cited a lack of medical necessity and lack of proper physician-patient relationships as a basis for many of their investigations and violations of the False Claims Act, especially in relationship to compounding pharmacies. Refuting these allegations may involve demonstrating that a proper doctor-patient relationship was established, that telemedicine protocol was followed, and / or medical services and products were necessary.
  • Intent – The Anti-Kickback Statute is an intent-based law, meaning that any remunerations received by physicians or other providers do not constitute a violation if their sole purpose was not to induce volume or value of referrals. Although the False Claims Act does not require proof of specific intent to constitute a violation, arguments of intent, though limited, may be raised to ensure those who made honest efforts to comply with the law are not held liable for claims with material inaccuracies due to accident or negligence.
  • Safe Harbors – Certain types of arrangements, such as personal services and management contracts, may fall under “safe harbors” that protect businesses from civil and criminal liability, provided that appropriate terms are met. For example, physicians who are paid by compounding pharmacies may argue that their relationship was a personal services and management safe harbor when there is evidence of an established agreement in writing of at least one year that covers all services provided, and which sets compensation consistent with fair market value in advance, without taking referrals into account.

How Is a TRICARE Audit or Investigation Initiated?

TRICARE contractors use statistical analysis and peer comparisons to identify potentially fraudulent claims behavior. Claims are software-reviewed on a pre- and post-payment basis to catch errors and overpayments. Other lead sources include whistleblower complaints, internal referrals from customer service or claims reviewers, and referrals from federal or state law enforcement agencies.

What Should I Do If I Am Contacted by a TRICARE Auditor?

If you receive a letter from TRICARE or one of its contractors requesting information or demanding recoupment for overpayment, or receive a Civil Investigative Demand from a federal law enforcement agency, contact the healthcare investigation attorneys at Hendershot Cowart P.C. immediately.

Even if you believe that you did nothing wrong or fraudulent, you cannot assume that everything will work out in your favor.

Our TRICARE audit attorneys can:

  • Handle communications with the auditor or investigator;
  • Help you prepare and present the requested documentation;
  • Appeal or negotiate the audit findings; and
  • Help protect you from fraud, waste, or abuse allegations that could lead to further investigations.

What Are the Potential Outcomes of a TRICARE Audit?

The resolution of an audit and investigation may include:

  • Provider training and education;
  • Prepayment monitoring;
  • Overpayment recovery;
  • Termination from TRICARE participation;
  • Civil monetary penalties; or
  • Referral to the appropriate federal or state law enforcement agency, such as Defense Criminal Investigative Services, for investigation and possible criminal prosecution.

What Are Common Examples of TRICARE Fraud or Abuse?

Today, the federal government has dramatically increased investigations into compounding pharmacies and other TRICARE healthcare providers, with a particular focus on identifying fraudulent or wasteful schemes involving:

  • Agreements or arrangements between either a marketing representative, supplier, provider, or beneficiary that result in claims which include unnecessary costs or charges (kickbacks)
  • Failure to establish a proper doctor-patient relationship
  • Auto-refill programs
  • Billing for services and/or supplies that were never performed or provided.
  • Misrepresentation of who received and/or rendered the services.
  • Billing non-covered services disguised as covered services.
  • Misrepresenting the description of services and/or dates of service.
  • Unbundling: The use of multiple codes to bill for a procedure when a single comprehensive code is the appropriate code to use.
  • Up-coding: Billing for a higher-level treatment than was actually provided. This error commonly occurs in the various evaluation and management codes.
  • Charging TRICARE rates in excess of those charges routinely charged by the provider to the general public.

Responding to TRICARE Audits & Fraud Prevention

Mitigating the impact of government demands, responding to authorities, and determining the most appropriate options for resolution and defense are matters that must be addressed on a case-by-case basis – and they should be addressed sooner, rather than later. The attorneys at Hendershot Cowart P.C. know the federal government has raised the stakes when it comes to TRICARE audits and fraud investigations, which is why we make ourselves immediately available to help providers across the step when they need it most.

We are also available to help healthcare providers establish policies and procedures that ensure they have compliant billing practices in place to help avoid audits and safeguard against fraud allegations.

To speak with a member of our team, send us a message online or call us at (713) 909-7323.

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