"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.
"Waste" is health care spending that can be eliminated without reducing 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.
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, Waste, and Abuse
|By a Member||By a provider|
|Using someone else’s insurance card.||False coding, altering records, or claims.|
|Altering or forging a prescription.||Balance billing by asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider's usual and customary fees.|
|Knowingly enrolling someone not eligible for coverage under their policy or group coverage.||Billing for services not rendered or goods not provided.|
|Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits.||Billing separately for services that should be a single service.|
|Altering the billed amount for services.||Billing for services not medically necessary.|
|Altering the service date.|| |
Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis.
Unbundling of procedures.
Health care fraud, waste, and abuse is rising higher and higher every year. Molina and other 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, waste, and abuse:
- Do not give your Molina ID card or number to anyone except your doctor, clinic, hospital or other healthcare provider.
- Do not let anyone borrow your Molina 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 ID card is lost or stolen, report it to Molina immediately.
Reporting Fraud, Waste, and 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, waste, and abuse to Molina Healthcare through one of the following:
To report an issue online, visit: https://molinahealthcare.AlertLine.com.
Insurance Fraud Bureau