Marketplace

Fraud, Waste, and Abuse Prevention

Molina Healthcare of South Carolina ("Molina") seeks to uphold the highest ethical standards for the provision of health care benefits and services to its members, and supports the efforts of federal and state authorities in their enforcement of prohibitions of fraudulent practices by providers or other entities dealing with the provision of health care services.

Definitions:

 
“Abuse” means practices that are inconsistent with sound fiscal, business or medical practices that result in an unnecessary cost to the Marketplace  or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Marketplace.

"Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

"Waste" is health care spending that can be eliminated without reducing the quality of care.

 
Federal False Claims Act, 31 USC Section 3279

The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. The act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment.The term "knowing" is defined to mean that a person with respect to information:
• Has actual knowledge of falsity of information in the claim;
• Acts in deliberate ignorance of the truth or falsity of the information in a claim; or
• Acts in reckless disregard of the truth or falsity of the information in a claim.
The act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted.

Health care fraud is:

Health care fraud includes but is not limited to the making of intentional false statements, misrepresentations or deliberate omissions of material facts from, any record, bill, claim or any other form for the purpose of obtaining payment, compensation or reimbursement for health care services.

Examples of Fraud and Abuse

By a Member

By a Provider

Using someone else’s insurance card.

False coding, altering records, or claims.
 Altering or forging a prescription.  Balance billing by asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider's usual and customary fees.

Knowingly enrolling someone not eligible for coverage under their policy or group coverage.

Billing for services not rendered or goods not provided.

Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits.

Billing separately for services that should be a single service.

Altering the billed amount for services.

Billing for services not medically necessary.

Altering the service date.

 

Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis.

Unbundling of procedures.
Upcoding

 
Preventing Fraud and Abuse
Healthcare fraud is rising higher and higher every year. Molina and other State and Federal agencies are working together to help prevent fraud. Here are a few helpful tips on how you can help prevent healthcare fraud and abuse:
• Do not give you Molina ID card or number to anyone except your doctor, clinic, hospital or other healthcare provider.
• Do not let anyone borrow your Molina ID card.
• Never lend your social security card to anyone.
• When you get a prescription make sure the number of the pills in the bottle matches the number on the label.
• Never change or add information on a prescription.
• If your Molina ID card is lost or stolen, report it to Molina immediately.
Reporting Fraud and Abuse
You may report suspected cases of fraud and abuse to Molina's Compliance Officer. You have the right to have your concerns reported anonymously to Molina, the South Carolina Office of the Attorney General’s Insurance Fraud Division, and/or United States Office of Inspector General. When reporting an issue, please provide as much information as possible. The more information provided the better the chance the situation will be successfully reviewed and resolved. Remember to include the following information when reporting suspected fraud or abuse:
 
  • Nature of complaint
  • The names of individuals and/or entity involved in suspected fraud and/or abuse including address, phone number, ID number and any other identifying information.

You may report fraud and abuse to Molina Healthcare through one of the following:

Telephone

The Molina Healthcare Alert Line is available 24/7. It can be reached at any time (day or night), over the weekend, or even on holidays.

Online

To report an issue online, visit: https://molinahealthcare.AlertLine.com.

Regular Mail

You may also report fraud, waste, and abuse to: