Fraud, Waste, and Abuse Prevention
Health care fraud, waste, and abuse is a national problem. It costs Americans billions of dollars every year. Molina Healthcare of South Carolina seeks to uphold the highest ethical standards when providing care and services to its members. Molina supports federal and state authorities in their role to stop health care fraud, waste, and abuse.
“Fraud” is an intentional deception or misrepresentation made by a person. The person does this act with the knowledge that the deception could result in unauthorized benefits to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law.
“Abuse” means practices that conflict with sound fiscal, business or medical practices. This results in costs that are not necessary to the South Carolina Medicare and Healthy Connections Medicaid programs. This can also lead to payment 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 Healthy Connections Medicaid/Medicare programs.
“Waste” is health care spending that can be done away with without reducing the quality of care. It is a misuse of resources.
Federal False Claims Act, 31 USC Section 3279
The False Claims Act is a federal law. This law covers fraud that impacts any federally funded contract or program. This includes, the Medicare and Medicaid programs. This law creates 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" means that a person:
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.
Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines.
Examples of Health Care Fraud, Waste, and Abuse
|By a Member||By a Provider|
|Using someone else’s insurance card.||Falsifying documents in order to get services paid.
Altering records in order to get services paid.
|Forging or altering a prescription.||Billing for services or goods not provided to the member.|
|Unbundling - when a provider bills parts of the service separately when they should have been billed all together as one service.
Upcoding - when a provider bills for complex care when the care was not complex.
|Giving misleading information. Leaving out information on an application for health care coverage. This includes intentionally giving incorrect information in order to get benefits.||Billing for services that are not medically necessary.
Billing for more units than what was provided.
|Balance Billing – asking the member to pay the difference between what Molina paid to the provider versus what the provider billed to Molina.|
|Kickbacks or Bribes – knowingly and willfully asks for or receives payment of kickbacks or bribes in exchange for the referral of Medicare of Medicaid members.|
|Stark Law Violation – knowingly and willfully referring Medicare or Medicaid patients to health care facilities that the referring provider has a financial relationship with.|
Preventing Fraud, Waste, and Abuse
Below are tips on how you can help prevent fraud, waste, and abuse:
Do not give your Molina Dual Options Member ID Card or number to anyone except your healthcare provider.
Do not let anyone borrow your Molina Dual Options Member ID Card.
Do not share your social security card.
Check your prescriptions. Make sure the number of pills in the bottle matches the number on the label.
Immediately report lost or stolen Molina Dual Options Member ID Card it to Molina Healthcare.
Reporting Fraud, Waste, and Abuse
You may report fraud, waste, and abuse to Molina Dual Options. You may anonymously report your concerns. Please give us as much information as possible when reporting an issue. The more information you are able to give us helps us when reviewing the issue. Remember to include the following information:
Nature of complaint.
Who was involved? We need the names of persons involved. This includes address, phone number, Medicaid ID number and any other information you may have.
When the issue happened.
Where the issue happened.
You may report fraud, waste, and abuse to Molina Dual Options through one of the following:
Call the toll-free number Molina Healthcare Alert-Line at: (866) 606-3889.
24 hours a day, 7 days a week
Report an issue online through a confidential and secure site at:https://MolinaHealthcare.AlertLine.com.
Report an issue in writing. Send your issue, marked confidential, to:
Molina Healthcare of South Carolina
4105 Faber Place Drive, Suite 470
Charleston, South Carolina 29405
You may also report fraud, waste, and abuse to the following agencies:
Department of Health and Human Services
Phone: (888) 364-3224
Office of the Attorney General
Phone: (803) 734-3660 or (888) 662-4328
Office of the Inspector General
P.O. Box 23489
Washington, DC 20026
HHS TIPS Fraud Hotline: 1-800-HHS-TIPS
Internet access is available at your local public library for those who do not have access to a computer.
*Materials are also available in printed formats.