Fraud, Waste, and Abuse Prevention
“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
- 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.
Health care fraud is:
|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.
Preventing Fraud, Waste, and Abuse
Health care fraud, waste, and abuse 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 health care fraud, waste, and abuse:
- 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.
- 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.
To report an issue online, visit: https://molinahealthcare.AlertLine.com.
200 East Gaines Street
Tallahassee, FL 32399
Toll-free: (877) MY-FL-CFO
Out of State: (850) 413-3089