Preventing Fraud, Waste and Abuse

fraud

Health care fraud is going up every year. Molina and the State of Texas are working together to help prevent waste, abuse and fraud.

These terms mean:

Fraud – Knowingly doing something to get a benefit or service that a person is not eligible to get or submitting false claims in order to receive payment.

Waste - Providing services that are not normally needed for care and do not add to the quality of care.

Abuse - Practices that don’t follow usual billing or care practices to increase payment. These practices can add unneeded costs.

Fraud, waste, and abuse hurts everyone. It raises taxes. It reduces funds available to pay benefits. It may even reduce the quality of care.

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. 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.

Helpful Tips for preventing fraud, waste and abuse:

Do’s

  • Protect your Medicaid and Medicare Number
  • Use a calendar to record all of your doctor’s appointments and any tests you get
  • Learn more about Medicaid or Medicare and recent scams
  • Know what your plan can and can’t do

Don’ts

  • Give your Medicaid or Medicare Number to anyone except your doctor or people you know should have it
  • Accept offers of money or gifts for free medical care
  • Allow anyone, except your doctor or other providers, to review your medical records or recommend services
  • Contact your doctor to request a service that you don’t need

Do you want to report Fraud, Waste or Abuse?

Let us know if you think a doctor, dentist, pharmacist at a drug store, or other health care provider is doing something wrong. Let us know if a person getting benefits is doing something wrong. Doing something wrong could be fraud, waste, or abuse. This is against the law. Tell us if you think someone is:

  • Getting paid for services that weren't given or necessary.
  • Not telling the truth about a medical condition to get medical treatment.
  • Letting someone else use their Medicaid ID.
  • Using someone else's Medicaid ID.
  • Not telling the truth about the amount of money or resources he or she has to get benefits.

To report waste, abuse, or fraud, pick one of the following:

Call the OIG Hotline at (800) 436-6184 or

  • Visit https://oig.hhsc.texas.gov/ and click the red “Report Fraud” box to complete the online form; or
  • You can report directly to your health plan:

Molina Healthcare of Texas
Attention: Director of Compliance
5605 N. MacArthur Blvd., Suite 400
Irving, Texas 75038
Molina Compliance/Anti-Fraud Hotline: (866) 606-3889

To report an issue online visit: https://molinahealthcare.AlertLine.com.

To report waste, abuse or fraud, get as much information as possible.

When reporting about a provider (a doctor, dentist, counselor, etc.) include:

  • Name, address, and phone number of provider
  • Name and address of the facility (hospital, nursing home, home health agency, etc.)
  • Medicaid number of the provider and facility, if you have it
  • Type of provider (doctor, dentist, therapist, pharmacist, etc.)
  • Names and phone numbers of other witnesses who can help in the investigation
  • Dates of events
  • Summary of what happened

When reporting about someone who gets benefits, include:

  • The person’s name
  • The person’s date of birth, Social Security Number, or case number if you have it
  • The city where the person lives
  • Specific details about the waste, abuse, or fraud