Fraud, Waste and Abuse in Florida
Compliance is everyone’s responsibility at Molina Healthcare. We support honest communication, safety and trust in line with our Code of Business Conduct and Ethics.
Fraud prevention tips
Molina Healthcare of Florida ("Molina") seeks to uphold the highest ethical standards for the provision of health care benefits and services to its members. Molina 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 Provider practices that are inconsistent with sound fiscal, business or medical practices and result in unnecessary costs to state and federal health care programs or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to state and federal health care programs. (42 CFR § 455.2).
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 themself or some other person. It includes any act that constitutes fraud under applicable Federal or State Law. (42 CFR § 455.2).
Health care fraud: 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.
Waste: means health care spending that can be eliminated without reducing the quality of care. Quality waste includes overuse, underuse and ineffective use. Inefficiency waste includes redundancy, delays and unnecessary process complexity. An example would be the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, but the outcome of poor or inefficient billing methods (e.g. coding) causes unnecessary costs to state and federal health care programs.
Deficit Reduction Act
On February 8, 2006, President Bush signed into law the Deficit Reduction Act (“DRA”). The law, which became effective on January 1, 2007, aims to cut fraud, waste and abuse from the Medicare and Medicaid programs over the next five years.
Health care entities, such as Molina, that receive or pay out at least $5 million in Medicaid funds per year must comply with DRA. As a contractor doing business with Molina, providers and their staff have the same obligation to report any actual or suspected violation of Medicare/Medicaid funds due to fraud, waste or abuse. Entities must have written policies that inform employees, contractors and agents of the following:
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:
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.
Examples of fraud, waste and abuse
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By a Member |
By a Provider |
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Lending an ID card to someone who is not entitled to it. |
Billing for services, procedures and/or supplies that have not actually been rendered |
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Altering the quantity or number of refills on a prescription. |
Providing services to patients that are not medically necessary. |
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Making false statements to receive medical or pharmacy services. |
Balance Billing a Medicaid member for Medicaid covered services. |
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Using someone else's insurance card. |
Double billing or improper coding of medical claims. |
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Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect information to receive benefits. |
Intentional misrepresentation of manipulating the benefits payable for services, procedures and/or supplies, dates on which services and/or treatments were rendered, medical record of service, condition treated or diagnosed, charges or reimbursement, identity of Provider/Practitioner or the recipient of services, "unbundling" of procedures, non-covered treatments to receive payment , "upcoding" and billing for services not provided. |
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Pretending to be someone else to receive services. |
Concealing patients' misuse of Molina Health card. |
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Falsifying claims. |
Failure to report a patient's forgery/alteration of a prescription. |
Other provider crimes
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 Florida 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:
You may report fraud and abuse to Molina Healthcare through one of the following:
1). The Molina Healthcare AlertLine that is available 24/7, 365 days a year
2). To report an issue by telephone, call (toll free): (866) 606-3889
3). To report an issue by fax: Compliance Manager – (866) 440-8591
4). To report an issue online, visit: https://www.MolinaHealthcare.AlertLine.com
5). To report an issue by mail, please direct your inquiry to:
Attn: Compliance Officer (CONFIDENTIAL)
Molina Healthcare of Florida
1030 W 49th St.
Hialeah, FL 33012
6). To report fraud against the Medicaid program, please write to:
Agency for Health Care Administration Bureau of Medicaid Program Integrity
2727 Mahan Drive, MS #6
Tallahassee, Florida 32308
Call toll-free: 1(888) 419-3456 (Option 5 is the Agency's Fraud and Abuse Hotline)
You may also use the Florida state on-line report form: https://apps.ahca.myflorida.com/mpi-complaintform/
You may also call the toll-free Statewide Hotline Number to Report Medicaid Fraud: 1-866-966-7226 (Florida Attorney General, Medicaid Fraud Control).
For those who do not have a computer or the internet at home, don’t worry. You can use one at your local public library.