TDP Fraud and Privacy
Fraud and abuse can take many forms. Examples of fraudulent and/or abusive practices include, but are not limited to:
- Submitting claims for services not rendered
- Submitting claims for non-covered services disguised as covered benefit services
- Identity thefts—Submitting claims for a non-eligible individual as a covered beneficiary
- Duplicate claims submissions
- Dentist misrepresents his or her credentials or conceals information regarding business practices which disqualifies him or her as an authorized TDP provider
- Improper billing practices, submitting claims for unnecessary dental services
- Routine waiver of member cost share
TRICARE sponsors and members have the ability and opportunity to detect fraud which may have occurred. The key is careful review of the DEOB. Make sure that the information on the DEOB matches the services you received.
- Verify the date of service.
- Verify the type of services rendered.
- Verify the payment issued was for the actual rendered services.
MetLife, as a federal contractor, is forbidden to pay claims for services rendered by those dentists or entities which have been sanctioned by the Department of Health and Human Services, Office of Inspector General (DHHS-OIG). Reasons for the sanctions include convictions for program-related fraud, patient abuse, and licensing board actions. The director of TMA (or designee) also has sanction authority. In either case, the dentist or entity that has been sanctioned has forfeited his or her entitlement to bill MetLife or the subscriber/member for the rendered services. MetLife will deny the services and issue a DEOB message which states that the dentist or entity may not bill anyone for the denied services.
On a monthly basis, the Government notifies MetLife of dentists or entities who have been sanctioned. The Government also includes a list of those individuals who have been reinstated.
Reporting Fraud and Abuse
If a subscriber or member believes a dentist or entity received insurance money through the submission of a false claim, he or she should report this information to the Special Investigations Unit (SIU).
Privacy Act Statement
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR 199.13, TRICARE Dental Program; 38 U.S.C. 1781, Medical Care for Survivors and Dependents of Certain Veterans; and E.O. 9397 (SSN), as amended.
PURPOSE: To obtain information from an individual to provide for enrollment, processing of claims, and customer service to individuals eligible for TRICARE Dental Program benefits.
ROUTINE USES: Information collected may be used and disclosed generally as permitted under 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, as implemented by DoD 6025.18-R, the DoD Health Information Privacy Regulation. In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act of 1974, the DoD “Blanket Routine Uses” under 5 U.S.C. 552a (b) (3) apply to this collection. Information from this system may be shared with federal, state, local, or foreign government agencies, and with private business entities, including individual providers of care, on matters relating to eligibility, claims pricing and payment, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil and criminal litigation.
DISCLOSURE: Voluntary. If you choose not to provide your information, no penalty may be imposed, but absence of the requested information may result in administrative delays or the denial of benefits.