Molina Healthcare of New Mexico (Molina Healthcare) 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.
“Abuse” happens when things are not done in line with good financial, business or medical practices. This can result in unnecessary costs and can result in payment for services that are not medically necessary. It can result in services that fail to meet professionally recognized standards for health care.
“Waste” is health care spending that is not necessary for appropriate quality of care. Quality waste includes overuse, underuse and ineffective use. Inefficiency waste includes doing more than what is needed. It can cause delays and result in processes that are not needed.
"Fraud" is an unfair or unlawful act. Fraud is done on purpose to get something of worth.
“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.||False coding, records, or altered 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.|
|Alerting the billed amount for services. Altering the service date.||Over utilization: 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.
- A practitioner knowingly and willfully referring Medicare or Medicaid patients to health care facilities in which or with which the practitioner 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 rising higher and higher every year. Molina Healthcare 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:
- Do not give you 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 Healthcare, the New Mexico Human Services Department Office of Inspector General, the Medicaid Fraud Control Unit, or the Medical Assistance Division. 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:
Fraud Alert Line toll-free: (866) 606-3889
Complete a report online: https://molinahealthcare.alertline.com/gcs/welcome.
Write (marked confidential) to: Compliance Officer, Molina Healthcare of New Mexico 400 Tijeras Ave NW, Suite 200, Albuquerque, NM 87102.
You can also report fraud, waste and abuse to:
Medical Assistance Division
Quality Assurance Bureau
P.O. Box 2348
Santa Fe, NM 87504-2348
Toll-free: (888) 997-2583
In Santa Fe: (505) 827-3100
Medicaid Fraud & Elder Abuse Division MFEAD
111 Lomas NW STE 300
Albuquerque, NM 87102
Toll-free: (800) 678-1508
In Albuquerque: (505) 222-9000
New Mexico Human Services Department
Office of Inspector General
Toll-free: (800) 228-4802
In Albuquerque: (505) 827-8141