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Fraud Prevention Tips

Molina Healthcare of California ("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 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).)

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

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

Altering the billed amount for services
Altering the service date

Overutilization: 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

  • A physician knowingly and willfully referring Medicare or Medicaid 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

    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 California Department of Health Services, 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 anonymously report fraud and abuse to Molina through one of the following:

    TELEPHONE
    Call the Toll-Free number of the Molina Healthcare of California,​
    Molina Healthcare AlertLine:
    (866) 606-3889

    WEBSITE
    www.MolinaHealthcare.alertline.com​

    REGULAR MAIL
    Write (marked confidential) to:
    Compliance Officer
    Molina Healthcare of California
    200 Oceangate, Suite 100
    Long Beach, CA 90802

    You may report fraud and abuse to the California Department of Health Care Services, or United States Office of Inspector General by:

  • Calling the toll-free number of the Department of Health Care Services Anti-Fraud Line: 800-822-6222 or sending an e-mail to: stopmedicalfraud@dhcs.ca.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:

    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
    http://cms.gov/

    Department of Managed Health Care
    California HMO Help Center
    980 Ninth Street, Suite 500
    Sacramento, CA 95814-2725
    Phone: 888-HMO-2219
    http://www.dmhc.ca.gov/

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

    Medi-Cal/California Department of Health Care Services
    (Information regarding Medi-Cal & State Licensing of Facilities)
    P.O. Box 997413, MS 4400
    Sacramento, CA 95899-7413
    Department of Health Care Services Anti-Fraud Line: 800-822-6222
    E-mail: stopmedicalfraud@dhcs.ca.gov
    http://www.dhcs.ca.gov

    For those who do not have access to computers in your home, Internet access is available at your local public library.

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