The federal government is cracking down on Tricare fraud, regularly auditing healthcare providers for signs of possible collusion or other forms of illegal activity. Tricare providers such as physicians, pharmacies, compound pharmacies, and toxicology groups are all facing audits by Express Scripts, which administers the Tricare Pharmacy Program. In particular, many providers are currently being audited, due to rumors of collusion between healthcare marketing groups and compound pharmacies.

While every audit is stressful, providers should not panic, nor should they respond to an audit too casually. To protect themselves and avoid costly mistakes, when confronted with an audit request for the first time, many providers seek the help of a Tricare-experienced healthcare attorney.

What Not to Do if You are Facing an Audit

Due to the legal implications of responding to a Tricare audit and the potential for further investigations, providers should not try to be helpful by providing information that the audit might not actually be requesting. Express Scripts audit questions can be confusing, and it is not advisable to try to provide what you think are the “right” or “correct” answers.

What to Do if You are Being Audited by Express Scripts

Instead of risking a mistake that can lead to follow-up audits, in-person audits, or even governmental investigations, Tricare providers should work with experienced Tricare attorneys to make sure that they are responding to their audits appropriately. An experienced Tricare attorney will be able to help you complete the audit without making costly mistakes.

Audit Question No. 5 (Express Scripts)

While most of Express Scripts Tricare audit questions focus on records and documentation, one question which is often the 5th question in Express Scripts standard audit protocol asks physicians whether they have directly or indirectly benefited from their referrals made to compound pharmacies. The purpose of this question is to uncover possible violations of the federal anti-kickback statute and the Stark Law, which governs physician referrals.

This is a complicated (and potentially dangerous) area, and physicians need to be extremely careful to avoid raising unnecessary suspicion. As a result, it is best to hire an attorney to help you understand the implications involved and craft an appropriate response.

Our Tricare Experience

The Criminal Defense Firm is a healthcare fraud defense law firm. All of our attorneys are intimately familiar with all nuances of healthcare law and have developed proven defense strategies to assist healthcare providers and marketing groups during Tricare and other healthcare audits and investigations.

Many of our attorneys served the Department of Justice in critical healthcare law positions prior to joining The Criminal Defense Firm

Our Tricare Clients

The Criminal Defense Firm is one of the country’s preeminent law firms in the area of Tricare audits and investigations. We advise clients across the country in Tricare-related matters. Some examples of our Tricare clients include:

Compound Pharmacies
CEO, Marketing Company
National Marketing Group
Regional Marketing Group
Physicians (TX, CO, CA, PA, NM and other states)
Toxicology Groups
DME Group