Our Commitment to Fight Health Care Fraud and Abuse

Health Net Federal Services, LLC (Health Net) 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 insure the integrity of the TRICARE Program.

Health Net 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 Health Net.

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:

  • dedicated Program Integrity staff
  • state-of-the-art fraud detection software
  • a special investigations unit
  • company-wide anti-fraud training
  • on-going 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

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