A Systematic Background Check of TRICARE Provider Names

Abstract

AbstractDuring Covid-19, the Defense Health Agency’s TRICARE insurance plan expanded its coverage to include 30.1% additional civilian healthcare providers. The DHA’s Annual Report, however, states that TRICARE’s provider directories are only 80% accurate. Although the DHA’s 9.6 million beneficiaries need expanded access to care, they also require protection from misleading information, medical fraud, patient abuse, and identity theft. Since 2013, the Department of Health and Human Services’ Office of the Inspector General has excluded 17,706 physicians from federal health programs due to misconduct. Patients who receive care from excluded providers experience worse medical outcomes. To determine if any excluded provider names were found on TRICARE’s website, we performed background checks on TRICARE West’s healthcare provider directory between January 1 and March 2023. Out of 39,463 provider names sampled from 22 states, there were 2,398 matches (6.08%) with individuals and businesses found in the OIG List of Excluded Individuals and Entities (OIG-LEIE), the GSA-SAM, the HHS HIPAA Breach Report, the International Trade Administration’s Consolidated Screening List, the OIG-HHS Fugitive List, the FBI’s January 6th Capitol Violence List of Charged Defendants, State Medicaid Exclusion Lists, and FDA Debarment Lists. Our study includes demographic analysis of the matching names and recommendations for an Insider Threat Management model. We recommend that DHA officials publish the National Provider Identification (NPI) numbers of all TRICARE providers. NPI numbers facilitate more accurate background checks of healthcare providers.