Anti-Fraud Program

Health care fraud, waste and abuse are a major problem. They can make taxes go up. They can cause quality of care issues. Molina Healthcare of New Mexico, Inc. (Molina Healthcare) works with state and federal agencies to detect, prevent and put a stop to these kinds of crimes.

State and federal laws require Molina Healthcare to report fraud, waste and abuse. Cases are sent to the government and/or law enforcement for investigation.

Why is it Important to Have an Anti-Fraud Program?

Health care fraud, waste and abuse is against the law. The Anti-Fraud program looks at these issues. They can harm the health plan. They can impact our ability to care for you.

• Detect;
• Prevent;
• Investigate; and
• Report.

What is Fraud?

Fraud is an unfair or unlawful act. Fraud is done on purpose to get something of worth.

What is Abuse?

Abuse happens when things are not done in line with good financial, business or medical practices. This can result in unnecessary costs. This can result in payment for services that are not medically necessary. It can result in services that fail to meet professionally recognized standards for health care. d

Who commits Fraud, Waste and Abuse?

Anyone can commit fraud, waste or abuse. This includes providers and members.

• Altering claims or medical records in order to get a higher payment;
• Balance billing, which is the practice of a provider billing a member for all charges not paid for by the health plan;
• Billing a procedure that does not match the diagnosis or problem;
• Billing for services that did not happen;
• Billing for services using a provider\rquote s name that did not provide care;
• False coding in order to get payment or get a higher payment;
• Charging members for drug samples;
• Having members come in for office visits more often than is needed;
• Questionable prescription practices;
• Questionable transportation services;
• Unbundling services in order to get more payment, which involves separating a procedure into parts and charging for each part rather than using a single code;
• Underutilization, which means failing to provide services that are medically necessary;
• Upcoding; which is when a provider does not bill the correct code for the service that was rendered and uses a code for a like service that costs more; and/or
• Waiving co-payments.

• Abusing transportation benefits (e.g. using ambulance services for non-emergencies);
• Doctor shopping in order to get services that are not needed;
• Drug seeking behavior;
• Drug trafficking;
• Forgery;
• Giving false information;
• Identity theft;
• Not paying co-payments;
• Not giving information to Molina Healthcare about other insurance coverage;
• Theft; and/or
• Using someone else's medical card;
  
  

  Reporting Fraud, Waste and Abuse

  Anyone with information about possible fraud, waste and abuse can make a referral. Referrals are sent to the Anti-Fraud program. If you make a referral, you can do so without giving your name. Information reported to the Anti-Fraud program will remain confidential to the extent possible as allowed by law.

  Molina Healthcare does not allow or tolerate retaliation against those, who in good faith, report potential fraud, waste and abuse to the Anti-Fraud program.

  You may report suspicious activity. You can do this in writing or by phone.

  Anti-Fraud Program Manager
  Molina Healthcare of New Mexico
  P.O. Box 3887
  Albuquerque, NM 87190-9859
  mhnm.compliance@molinahealthcare.com
  Toll free Compliance & Anti-Fraud Hotline: (800) 827-2973
  In Albuquerque: (505) 341-7469
  Toll free fax: (866) 472-4580

  Give as much information as possible when making a referral. The Anti-Fraud program needs to know:
  • Who is the suspect?
  • What is the suspect's name?
  • When did the possible fraud, waste and abuse happen?
  • Where did the possible fraud, waste and abuse happen?
  • Why do you think the possible fraud, waste and abuse happened?
  • How did the possible fraud, waste and abuse happen?

  The more detail you can give the Anti-Fraud program, the better the chances the issue will be successfully reviewed and resolved.

  You can also report fraud, waste and abuse to:

  Medical Assistance Division
  Quality Assurance Bureau
  P.O. Box 2348
  Santa Fe, NM 87504-2348
  NMMedicaidFraud@state.nm.us
  Toll free: (888) 997-2583
  In Santa Fe: (505) 827-3100
  
  Medicaid Fraud Control Unit
  111 Lomas NW, Suite 300
  Albuquerque, NM 87102
  Toll free: (800) 678-1508
  In Albuquerque: (505) 222-9000
  
  New Mexico Human Services Department
  Office of Inspector General
  Toll free: (800) 228-4802
  In Albuquerque: (505) 827-8141
  HSDOIGFraud@state.nm.us
  
  Such services are funded in part under contract with the State of New Mexico.

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