“Abuse” means practices that are inconsistent with sound fiscal, business or medical practices that result in an unnecessary cost to the Medicaid/Medicare programs 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 Medicaid/Medicare programs. (42 CFR 455.2 and as further defined in Welf. & Inst. Code Section 14043.1 (a).)
"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 or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 455.2 W. & I. Code Section14043.1(i).)
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:
- 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||By a Provider|
|Using someone else’s insurance card.||Falsifying codes or records, or altering claims.|
|Forging a prescription.||Billing for services not rendered 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 on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits.||Billing for services not medically necessary.|
|Altering the billed amount for services. Altering the service date.||Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis.|
Other Provider Crimes
- Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients. (Anti-Kickback Statute)
- Knowingly and willfully referring Medicare or Medicaid patients to health care facilities in which or with which the provider 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
Healthcare fraud is on the rise. Molina and 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:
- Do not give your Molina Healthcare ID Card or number to anyone except your provider, clinic, hospital or other healthcare provider.
- Do not let anyone borrow your Molina Healthcare 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 Healthcare ID Card is lost or stolen, report it to Molina Healthcare immediately.
Reporting Fraud and Abuse
You may report suspected cases of fraud and abuse to Molina Healthcare's Compliance Officer. You have the right to have your concerns reported anonymously to Molina Healthcare, and/or United States 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:
- 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 may report fraud and abuse to Molina Healthcare through one of the following:
Molina Healthcare of Illinois Compliance: MHILCompliance@MolinaHealthcare.com
Call the Molina Healthcare toll-free confidential compliance anti-fraud hotline at (866) 606-3889.
Fax Molina Healthcare of Illinois: (630) 571-1220
Write (marked confidential) to:
Molina Healthcare of Illinois
Attn: Compliance Officer
1520 Kensington Road, Suite 212
Oak Brook, Illinois 60523
You may report fraud and abuse to the United States Office of Inspector General by:
- 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 the following website: http://www.oig.hhs.gov
Office of the Inspector General (HCFA-OIG)
OIG List of Excluded Individuals (Listing of Health Care Providers who've been excluded from Federal Participation)
P.O. Box 23489
Washington, DC 20026
HHS TIPS Fraud Hotline: 1-800-HHS-TIPS