Molina Healthcare of Mississippi 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. 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
- Lending an ID card to someone who is not entitled to it.
- Altering the quantity or number of refills on a prescription.
- Making false statements to receive medical or pharmacy services.
- Using someone else’s insurance card.
- Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect information to receive benefits.
- Pretending to be someone else to receive services.
- Falsifying claims.
By a Provider
- Billing for services, procedures and/or supplies that have not been actually been rendered.
- Providing services to patients that are not medically necessary.
- Balancing Billing a Medicaid member for Medicaid covered services.
- Double billing or improper coding of medical claims.
- 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.
- Concealing patients misuse of Molina Health card.
- Failure to report a patient’s forgery/alteration of a prescription.
- Submits a claim for payment which contains any materially false or misleading information.
Other Provider Schemes
- Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients.
- 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)
- Balance billing - asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider's usual and customary fees.
Preventing Fraud and Abuse
Molina and other State and Federal regulatory and law enforcement agencies are working together to help prevent fraud, waste, and abuse. Here are a few helpful prevention tips:
- Do not give your 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 Mississippi State Attorney General’s Medicaid Fraud Control Unit, and/or The United States Office of Medicaid 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, Medicaid ID number and any other identifying information.
You can report fraud in several ways. You can contact Molina’s Compliance Office:
- Phone Toll Free: (866) 606-3889
- Fax: Attention Compliance (844) 879-4471
- Report Online: https://molinahealthcare.alertline.com
- Mail:
Attention: Compliance (CONFIDENTIAL)
Molina Healthcare of Mississippi, Inc.
118 E. Capitol Street, Suite 700
Jackson, MS 39201
You can also contact the Mississippi Division of Medicaid’s Office of Program Integrity:
- Phone Toll Free: (800) 880-5920
- Phone: (601) 576-4162
- Fax: (601) 576-4161
- Report Online: http://www.medicaid.ms.gov
- Mail:
550 High Street, Suite 1000
Jackson, MS 39201
To report suspected Medicaid fraud, waste, or abuse in Mississippi, contact the Mississippi Attorney General Medicaid Fraud Control Unit toll free at 1(800) 852-8341 or email:
mfcu@ago.state.ms.us.
The Office of the Medicaid Inspector General (OMIG) Fraud Hotline toll free: 1 (877) 87FRAUD or 1 (877) 873-7283
For those who do not have a computer or the internet at home, don’t worry. You can use one at your local public library.
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