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| WASTE, FRAUD, AND ABUSE
INFORMATION |
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| Molina Healthcare of Texas
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. |
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| Definitions: |
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| "Abuse" means provider practices that are inconsistent with sound
fiscal, business, or medical practices, and result in unnecessary cost to the
Medicaid program or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for health
care. It also includes recipient practices that result in unnecessary cost to
the Medicaid program. (42 CFR §455.2)
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| "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. (42 CFR § 455.2)
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| Federal False Claims Act, 31 USC Section 3279
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| 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. |
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| The term "knowing" is defined to mean that a person with respect to
information: |
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Has actual knowledge of falsity of information in the
claim; |
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Acts in deliberate ignorance of the truth or falsity
of the information in a claim; or |
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Acts in reckless disregard of the truth or falsity of
the information in a claim. |
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| 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. |
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| Health care fraud is:
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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.
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| Examples of Fraud and Abuse |
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| By a Member |
By a Provider |
| Lending an ID card to someone who is not entitled to
it. |
Billing for services, procedures and/or supplies that
have not been actually been rendered |
| Altering the quantity or number of refills on a
prescription
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Providing services to patients that are not medically
necessary |
| Making false statements to receive medical or pharmacy
services |
Balancing Billing a Medicaid member for Medicaid
covered services |
| Using someone else's insurance card
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Double billing or improper coding of medical claims |
| Including misleading information on or omitting
information from an application for health care coverage or intentionally
giving incorrect information to receive benefits |
Intentional misrepresentation of manipulating the
benefits payable for services, procedures and or supplies, dates on which
services and/or treatments were rendered, medical record of service, condition
treated or diagnosed, charges or reimbursement, identity of
Provider/Practitioner or the recipient of services, "unbundling" of procedures,
non-covered treatments to receive payment , "upcoding", and billing for
services not provided |
| Pretending to be someone else to receive services |
Concealing patients misuse of Molina Health card |
| Falsifying claims |
Failure to report a patient's forgery/alteration of a
prescription |
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| Other Provider Crimes |
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Knowingly and willfully solicits or receives payment of kickbacks
or bribes in exchange for the referral of Medicare or Medicaid patients. |
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A physician knowingly and willfully referring Medicare or Medicaid
patients to health care facilities in which or with which the physician has a
financial relationship. (The Stark Law) |
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Balance billing - asking the patient to pay the difference between
the discounted fees, negotiated fees, and the provider's usual and customary
fees. |
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| Preventing Fraud and Abuse |
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| 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: |
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Do not give you Molina ID card or number to anyone except your
doctor, clinic, hospital or other healthcare provider |
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Do not let anyone borrow your Molina ID card. |
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Never lend your social security card to anyone. |
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When you get a prescription make sure the number of the pills in
the bottle matches the number on the label. |
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Never change or add information on a prescription. |
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If your Molina ID card is lost or stolen, report it to Molina
immediately. |
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| Reporting Fraud and Abuse |
| You may report suspected cases of fraud and abuse to Molina's
Compliance Manager. You have the right to have your concerns reported
anonymously to either Molina and/or the Texas Department of Health and Human
Services Commission, Office of Inspector General (OIG) |
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| Remember to include the following information when reporting
suspected fraud or abuse: |
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Nature of complaint |
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The names of individuals and/or entity involved in suspected fraud
and/or abuse including address, phone number, Medicaid ID number and any other
identifying information.
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| Molina Healthcare of Texas Confidential Compliance Hotline Voice
Mail: 866-887-1748 |
| Email: MHT-complaince@Molinaheathcare.com |
To submit written report via mail or fax:
Mail:
Compliance Manager
Molina Healthcare of Texas
84 NE Loop 410, Suite 200, San Antonio, TX. 78216
Fax: 866-887-1749
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| You may also report suspected fraud and abuse related directly to
the Texas Department of Health and Human Services Commission, Office of
Inspector General (OIG): |
Mail:
Office of Inspector General
General Investigation
P.O. Box 85200
Austin, TX. 78708-5200
Telephone:
800-436-6184
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Website:
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