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Fraud Prevention

Molina Healthcare of South Carolina 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 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).)

"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 to the Medicaid/Medicare programs.  

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
  • 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.

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. (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
Health care 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 health care fraud and abuse:
  • Do not give your Molina Healthcare ID Card or number to anyone except your provider, clinic, hospital or other health care 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, the South Carolina Division of Program Integrity 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:

Telephone
Call the Molina Healthcare toll-free compliance anti-fraud line at (866) 606-3889.

Email
Molina Healthcare of South Carolina Compliance:
https://www.molinahealthcare.alertline.com   

Regular Mail
Write (marked confidential) to:
Attn: Compliance Director (CONFIDENTIAL)
Molina Healthcare of South Carolina
4105 Faber Place Drive, Suite 120
Charleston, South Carolina 29405

Or go online to: https://molinahealthcare.AlertLine.com

You may report fraud and abuse to the South Carolina Department of Health and Human Services (SCDHHS) Division of Program Integrity, or United States Office of Inspector General by:

  • Calling the toll-free number for SCDHHS Division of Program Integrity's Medicaid Fraud Hotline: (888) 364-3224, sending to the Fraud fax number (803)255-8224 or by sending an e-mail to fraudres@scdhhs.gov
  • 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 any of the following websites:

Office of the Inspector General (HCFA-OIG)
OIG List of Excluded Individuals (Listing of Health Care Providers who've been excluded form Federal Participation)     P.O. Box 23489, Washington, DC 20026
HHS TIPS Fraud Hotline: 1-800-HHS-TIPS
http://www.oig.hhs.gov/

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