Molina Healthcare of Ohio (Molina) upholds the highest ethical standards in providing health care benefits and services to our members. Molina supports federal and state agencies in preventing and reporting fraudulent practices by providers and other entities providing health care services.
“Abuse” means practices that are inconsistent with sound fiscal, business or medical practices that result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary cost to the Medicaid program. (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. Health care providers can be prosecuted (have legal action taken against them) for a wide range of conduct that leads to the submission of fraudulent claims to the government. This includes making false statements on purpose, falsifying records and double-billing for items or services. It also includes sending bills for services never performed or items never furnished or causing a false claim to be submitted.
Health care fraud is:
Health care fraud includes but is not limited to:
- Making false statements on purpose
- Misrepresenting or leaving out material facts on purpose from any record, bill, claim or any other form for the purpose of getting 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 changed claims.|
|Forging a prescription.||Billing for services not given or goods not provided.|
|Enrolling someone not eligible for coverage under your policy or group coverage on purpose.||Billing separately for services that should be a single service.|
|Providing misleading information on or leaving out information from an application for health care coverage, or giving incorrect information on purpose to receive benefits.||Billing for services not medically needed.|
|Changing the billed amount for services. Changing the service date.||Over utilization: Medically unneeded diagnostics (tests), unneeded durable medical equipment, unapproved services, or wrong procedure for diagnosis.|
Other Provider Crimes
- Knowingly and willfully requests or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients.
- A provider knowingly and willfully refers Medicare or Medicaid patients to health care centers 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
Health care fraud is rising every year. Molina and other state and federal agencies work together to help prevent fraud. Here are a few tips on how you can help prevent health care fraud and abuse:
- Do not give your Molina ID card or number to anyone except your doctor, clinic, hospital or other health care 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 as soon as you know it's missing.
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 (without anyone knowing who you are) to Molina, the Ohio Department of Health and Human Services and/or United States Office of Inspector General. When reporting an issue, provide as much detail as possible. The more details provided, the better the chance the case will be reviewed and resolved. Remember to include the following when reporting suspected fraud or abuse:
- Nature of complaint
- The names of people and entities involved in suspected fraud and/or abuse.
- Details about the people and entities, including address, phone number, Medicaid ID number and any other information you can give.
You may report fraud and abuse to Molina Healthcare by phone, online or by mail:
Confidential Compliance Hotline at (866) 606-3889.
You may report fraud and abuse to the Ohio Department of Medicaid by phone, online or by mail:
Ohio Department of Medicaid
Bureau of Managed Care
P.O. Box 182709
Columbus, OH 43218-2709
You may report fraud and abuse to the Ohio Attorney General’s Office Medicaid Fraud Control Unit (MFCU) by phone or online:
You may report fraud and abuse to the Ohio Auditor of State (AOS) by phone or email:
(866) 372-8364 (866-FRAUD-OH)
More Health Care Compliance and Anti-Fraud & Abuse Information may be accessed at the website(s) below:
Centers for Medicare & Medicaid Services
(Information Relative to the Medicare Program and National Health Care Laws) 90 7th Street, Suite 5–300 (5W), San Francisco, CA 94103-6707