The Tricare program is once again the target of fraudulent claims. The health insurance program for members of the U.S. military, their family and retired military, has been bilked millions of dollars for unnecessary genetic tests and drug screening, according to media reports.
The latest alleged Tricare scam goes something like this: Labs set up makeshift clinics and entice soldiers and their families to have tests conducted in exchange for gift cards or other financial incentives. The patients’ personal information — social security numbers, military IDs and insurance billing information — is then used to bill the program. In one instance, patients were recruited via an ad on Craigslist to undergo genetic testing, which can cost the insurer thousands of dollars each.
According to the report, recruiters use “hardball” pitches to get doctors to order the tests which are then billed to Tricare.
This isn’t the first such fraud investigation involving Tricare billing. Last August, and again in February, we wrote about how the U.S. Department of Justice has been investigating fraudulent billing practices involving compounding pharmacies and specialty creams. Tricare is believed to be the largest target of the alleged fraud.
The lawsuits and investigations raise legal and ethical questions about business relationships between doctors and pharmacies. Federal law prohibits physicians from receiving anything of value in exchange for referrals.
While there are unscrupulous providers, some also may become the target of dodgy actors who cause them to unwittingly sign or authorize certifications of medical necessity in the course of business without personally verifying the need for those services.
Although safe harbors do exist that allow providers to receive payments for legitimate services, these deals must be structured within the confines of the law.
It is imperative the physicians and other healthcare providers take care to ensure that they see each patient for whom a test is ordered or a prescription is written. Having a legitimate physician–patient relationship and providing proper documentation is the first step to a successful defense.
Investigations are underway across several states focusing on false claims and kickback arrangements. Physicians would be well-advised to contact their healthcare law attorney before signing any agreements or allowing the use of their provider numbers to bill any healthcare insurance company. Ignorance is not a defense.
Should you become the target of an investigation it is imperative that you seek immediate legal counsel.
The Health Law Offices of Anthony C. Vitale has been representing clients under investigation for 25 years. The firm conducts confidential defense investigations and will take you through the process in an effort to reduce or eliminate criminal, civil, licensure and administrative liability.
We can be reached at 305 358-4500 or email us at firstname.lastname@example.org.