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Fraud

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Fraud, Waste and Abuse Prevention

Molina Healthcare of Wisconsin ("Molina") supports the highest ethical standards for providing healthcare benefits and services to its members. Molina supports the work of federal and state authorities to prevent fraud, waste and abuse by providers. This includes those who help with providing healthcare services.

Definitions:

“Abuse” means acts that do not meet sound fiscal, business or medical practices. These acts result in needless cost to the Medicaid or Medicare programs. They may result in payment for services that are not medically needed. They may also fail to meet the bet standards for health care. It also includes acts by members that cause needless cost to the Medicaid or Medicare programs.

"Fraud" means a planned deception or false account of information. It is fraud when a person knows that the deception could result in illegal benefit. The illegal benefit might be for himself or another person. It includes any act that is defined as fraud under Federal or State law.

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

Federal False Claims Act, 31 USC Section 3279

The False Claims Act is a federal law.  This law covers fraud for any contract or program that receives money from the federal government. This includes Medicare and Medicaid programs. The law declares liability for any person who knowingly asks the U.S. government for payment for fake services or goods.  The term "knowing" means that a person: :

  • Has actual knowledge of false information in the claim;
  • Acts in deliberate ignorance of the truth or false information in a claim; or
  • Acts in reckless disregard of the truth or false 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 accused for a wide variety of acts. These acts lead to sending false claims to the government. These include:.

  • Knowingly making false statements
  • Creating false records
  • Double-billing for items or services
  • Sending bills for services never performed
  • Sending bills for items never furnished
  • Causing a false claim to be submitted

 

Health care fraud:

Health care fraud includes, but is not limited to, making intentional false statements. False statements include false accounts or purposely leaving out material facts from records used for billing.  Records include any record, bill, claim or any other form to obtain payment 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.
Billing for services or goods not provided.
Knowingly enrolling someone not eligible for coverage under their policy or group coverage.
Billing separately for services that should be a single service.
Providing misleading information or omitting information from an application for health care coverage. This includes purposely giving the wrong information to recieve benefits.
Billing for services not medically needed.
Altering the billed amount for services. Altering the service date.
Providing tests, durable medical equipment, or services that are not medically needed. Providing incorrect services based on the diagnosis.

Other Provider Crimes

  • Knowingly and willfully asking for or receiving payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients.
  • A doctor knowingly and willfully referring Medicare or Medicaid patients to health care facilities that have a financial relationship with the doctor. (The Stark Law)
  • Balance billing - asking you to pay the difference between the fees agreed upon with the plan and providers normal fees.

Preventing Fraud and Abuse

Health care fraud is rising every year. Molina and other State and Federal agencies are working together to help prevent fraud. Here are some ways you can help:

  • Do not give you Forward Health ID card or number to anyone except your doctor, clinic, hospital or other healthcare provider.
  • Do not let anyone borrow your Forward Health ID card.
  • Never lend your social security card to anyone.
  • When you get medicine, 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 Forward Health ID card is lost or stolen, report it to your case worker immediately.

Reporting Fraud and Abuse

If you think you have seen an act of fraud or abuse, you may report it to Molina's Compliance Officer. You can report your concerns without giving your name to Molina. You can also report your concerns to the Wisconsin Department of Health Services. You can also report it to the United States Office of Inspector General. When reporting an issue, please give as much information as possible. The more facts you give, the better the chance the situation will be reviewed and resolved. Remember to give the following information when reporting suspected provider fraud or abuse: 

  • Type of complaint
    • Name, address, and phone number of provider
    • Name and address of the facility (hospital, nursing home and home health agency, etc.)
    • Medicaid number of the provider and facility is helpful
    • Type of provider (physician, physical therapist, and pharmacist, etc.)
    • Names and number of other people who can aide in the review
    • Dates of event
    • Describe what happened in detail.

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

Telephone

The Molina Healthcare AlertLine is available 24/7.  It can be reached at any time (day or night), over the weekend, or even on holidays.  To report an issue by telephone, call toll-free at (866) 606-3889.

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

You can also report fraud, waste and abuse to:

Wisconsin Department of Health Services or United States Office of Inspector General by sending a letter or fax. You can also call their office.

Department of Health Services
Public Assistance Fraud Unit
Attention: Fraud Prevention Investigation
P.O. Box 309
Madison, WI 53701-309

Phone: (877) 865-3432
Fax: (608) 261-7792, Attn: DHS Fraud Prevention Program
Call the toll-free number of the Office of Inspector General: (800) 447-8477

More Health Care Compliance and Anti-Fraud & Abuse Information may be found by visiting any of the following websites: 

Complete a report form online at: https://molinahealthcare.alertline.com/gcs/welcome

You may report fraud and abuse to the Wisconsin Department of Health Services or United States Office of Inspector General by:

Department of Health Services
Public Assistance Fraud Unit
Attention: Fraud Prevention Investigation
P.O. Box 309
Madison, WI 53701-309

Phone: (877) 865-3432
Fax: (608) 261-7792, Attn: DHS Fraud Prevention Program
Calling the toll-free number of the Office of Inspector General: (800) 447-8477

Additional Health Care Compliance and Anti-Fraud & Abuse Information may be accessed by visiting any of the following websites:

Centers for Medicare & Medicaid Services

(Information Relative to the Medicare Program and National Health Care Laws)90 7th Street, Suite 5–300 (5W),San Francisco, CA 94103-6707 http://cms.gov/

Office of the Inspector General (HCFA-OIG)

OIG List of Excluded Individuals (Listing of Health Care Providers who've been excluded form Federal Participation)P.O. Box 23489,Washington, DC 20026 HHS TIPS Fraud Hotline: 1-800-HHS-TIPS http://www.oig.hhs.gov/

 

 

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