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Our Commitment to Fight Health Care Fraud and Abuse

Most TRICARE providers and beneficiaries are honest. Some are not. Fraud is when someone knowingly gives false information that allows someone to get a benefit that is not allowed. Abuse is when someone knowingly take actions that result in unnecessary cost or services.

Health Net Federal Services, LLC (HNFS) has an entire team dedicated to combating fraud, waste and abuse against the TRICARE program. HNFS’ Program Integrity unit employs knowledgeable professionals dedicated to detecting, investigating, preventing, and remedying fraud, waste and abuse. The team includes investigators with over three decades of TRICARE experience who collaborate with certified medical coding auditors and clinical nurse reviewers to resolve allegations against providers and/or beneficiaries.

HNFS reviews every allegation of fraud, waste and abuse thoroughly. If there are clear indications of intent to defraud or serious issues concerning quality of patient care, we will refer the case to the government for further investigation and possible prosecution.

Billions of dollars are lost to health care fraud every year. Our Program Integrity team is highly effective at recovering dollars that would otherwise be lost to instances of fraud, waste or abuse. Between January 2022 and December 2022, we reviewed nearly 300 cases and recovered millions of dollars for the TRICARE program.

What is health care fraud and abuse?

Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment.

Examples of fraud

  • submitting claims for services not provided or used
  • falsifying claims or medical records
  • misrepresenting dates, frequency, duration or description of services rendered
  • billing for services at a higher level than provided or necessary
  • falsifying eligibility
  • failing to disclose coverage under other health insurance

Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.

Examples of abuse

  • a pattern of waiving cost-shares or deductibles
  • failure to maintain adequate medical or financial records
  • a pattern of claims for services not medically necessary
  • refusal to furnish or allow access to medical records
  • improper billing practices

How do I report fraud or abuse?

One way you can help stop fraud, waste and abuse is to review your Explanation of Benefits (EOB) once we've processed a claim. Look for any service that you did not receive or any provider you did not see.

If you think fraud that has occurred, you can report it securely.

Visit our How to Report Fraud and Abuse page for more information.