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Members

Fraud, Waste, and Abuse Prevention

Molina Healthcare of South Carolina ("Molina") 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 provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs and services.

"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)

"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).)

"Waste" means health care spending that can be eliminated without reducing the quality of care. Quality Waste includes, overuse, underuse, and ineffective use. Inefficiency Waste includes redundancy, delays, and unnecessary process complexity. For example: the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, however the outcome of poor or inefficient billing methods (e.g. coding) causes unnecessary costs.
 
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

Lending an ID card to someone who is not entitled to it.

Billing for services, procedures and/or supplies that have not been actually been rendered.

Altering the quantity or number of refills on a prescription.

Providing services to patients that are not medically necessary.

Making false statements to receive medical or pharmacy services.

Balancing Billing a member for covered services.

Using someone else's insurance card.

Double billing or improper coding of medical claims.

Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect information to receive benefits.

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.

Pretending to be someone else to receive services.

Concealing patients misuse of Molina Health card.

Falsifying claims.

Failure to report a patient's forgery/alteration of a prescription.


 
Other Provider Crimes
 
  • Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of patients.
  • A physician knowingly and willfully referring 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

Healthcare fraud 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 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, the South Carolina Office of the Attorney General’s Insurance Fraud Division, 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, ID number and any other identifying information.


You may report fraud and abuse to Molina Healthcare through one of the following:

The Molina Healthcare AlertLine is available 24/7, 365 days a year.

To report an issue by telephone, call (toll free): (866) 606-3889

To report an issue online, visit: https://www.MolinaHealthcare.AlertLine.com

To report an issue by mail, please direct your inquiry to:

Attn: Compliance Director (CONFIDENTIAL)
Molina Healthcare of South Carolina
4105 Faber Place Drive, Suite 120
Charleston, South Carolina 29405

To report fraud, please contact:

Insurance Fraud Division
Office of the Attorney General
P. O. Box 11549
Columbia, SC 29211-1549 http://www.scag.gov/insurance-fraud
Telephone: (803) 737-6424 Fax: (803) 734-0084or call toll-free: Call 1-888-95-FRAUD

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