Molina Healthcare of Idaho 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
“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
"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
"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;
- 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.
Falsifying codes or records, or altering 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
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
Billing for services not medically necessary.
Alerting 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. (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
Healthcare 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 healthcare fraud and abuse:
- Do not give your Molina Healthcare ID Card or number to anyone except your provider,
clinic, hospital or other healthcare 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
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, 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
- 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:
Call the Toll-Free number of the
Molina Healthcare Anti-Fraud Line: