Health Net Federal Services, LLC (HNFS) has an entire department dedicated to combating health care fraud and abuse committed against the TRICARE program. This department is called Program Integrity, and like the name, the mission is to ensure the integrity of the TRICARE Program.
Health Net Federal Services embraces a team approach in all areas. Program Integrity is no exception. The Program Integrity Department is comprised of investigators, nurses, analysts and claims specialists. However, the fraud team includes all associates within HNFS.
Each report of potential fraud or abuse goes through an exhaustive review process. Cases in which there is clear evidence of intent to defraud or serious issues concerning quality of patient care are referred to the government for further investigation and possible prosecution.
These are just some of the steps our company has taken to combat health care fraud and abuse:
- dedicated Program Integrity staff
- state-of-the-art fraud detection software
- special investigations unit
- company-wide anti-fraud training
- ongoing coordination with federal authorities
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?