Fraud, waste and abuse in California
Compliance is everyone’s responsibility at Molina. We support honest communication, safety and trust in line with our Code of Business Conduct and Ethics.
Molina seeks to uphold the highest ethical standards for the provision of health care benefits and services to members. We support 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 provider practices that are inconsistent with sound fiscal, business or medical practices and that result in unnecessary costs to state and federal health care programs 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 state and federal health care programs. (42 CFR § 455.2).
Conviction or convicted means that a judgment of conviction has been entered by a federal, state or local court, regardless of whether an appeal from that judgment is pending (42 CFR 455.2). This definition also includes the definition of the term “convicted” in Welfare and Institutions Code Section 14043.1 (f).
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/herself or some other person. It includes any act that constitutes fraud under applicable federal or state law. (42 CFR § 455.2).
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.
Waste means health care spending that can be eliminated without reducing the quality of care. Quality waste includes overuse, underuse and ineffective use. Inefficiency waste includes redundancy, delays and unnecessary process complexity. One example is the attempt to obtain reimbursement for items or services where there is no intent to deceive or misrepresent; however, the outcome of poor or inefficient billing methods (e.g., coding) causes unnecessary costs to state and federal health care programs.
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:
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.
Examples of fraud, waste and abuse
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By a member |
By a provider |
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Lending a member ID card to someone who is not entitled to it |
Billing for services, procedures and/or supplies that have not actually been rendered |
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Altering the quantity or number of refills on a prescription |
Providing services to patients that are not medically necessary |
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Making false statements to receive medical or pharmacy services |
Balance-billing a Medicaid member for Medicaid-covered services |
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Using someone else's member ID card |
Double-billing or improper coding of medical claims |
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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 |
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Pretending to be someone else to receive services |
Concealing a patient’s misuse of a Molina member ID card |
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Falsifying claims |
Failure to report a patient's forgery/alteration of a prescription |
Other provider crimes
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 California Department of Health Care Services (DHCS) and/or U.S. 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:
You may report fraud and abuse to Molina Healthcare:
To report fraud against the Medicaid program, please call DHCS at (800) 822-6222 or email stopmedicalfraud@dhcs.ca.gov. Or call the U.S. Office of Inspector General at (800) 447-8477.
Additional health care compliance and anti-fraud/abuse information may be accessed by visiting the following websites:
Centers for Medicare & Medicaid Services
(Information about Medicare and national health care laws)
90 7th Street, Suite 5–300 (5W)
San Francisco, CA 94103-6707
www.CMS.gov
Department of Managed Health Care
California HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
Phone: (888) 466-2219
www.dmhc.ca.gov
Office of the Inspector General
(HCFA-OIG) OIG List of Excluded Individuals
P.O. Box 23489
Washington, DC 20026
HHS TIPS Fraud Hotline: (800) HHS-TIPS
www.oig.hhs.gov
Medi-Cal/California Department of Health Care Services
(Information regarding Medi-Cal & state licensing of facilities)
P.O. Box 997413, MS 4400
Sacramento, CA 95899-7413
Department of Health Care Services Anti-Fraud Line: (800) 822-6222
E-mail: stopmedicalfraud@dhcs.ca.gov
www.dhcs.ca.gov