Fraud, waste & abuse in Illinois
Compliance is everyone’s responsibility, and Molina Healthcare supports honest communication, safety, and trust in alignment with our Code of Business Conduct and Ethics.
Fraud prevention tips
Molina Healthcare seeks to uphold the highest ethical standards for the provision of health care benefits and services to 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: 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: 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: 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: Health care spending that can be eliminated without reducing the quality of care. Quality waste includes overuse, under use, 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, however the outcome of poor or inefficient billing methods (e.g., coding) causes unnecessary costs to state and federal health care programs.
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
Please review the Molina Healthcare Provider Manuals for examples of fraud, waste and abuse by members and providers.
Reporting fraud, waste 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 Illinois Division of Program Integrity, 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.
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, year-round.
2). To report an issue by telephone, call (toll free): (866) 606-3889
3). To report an issue online, visit: MolinaHealthcare.AlertLine.com
4). To report an issue by mail, please direct your inquiry to:
Molina Healthcare of Illinois, Inc.
Attn: Compliance Officer (CONFIDENTIAL)
2001 Butterfield Rd., Suite 750
Downers Grove, IL 60515
Phone: (888) 858-2156
Suspected fraud and abuse may also be reported directly to CMS:
Phone: (800) 633-4227 [(800) MEDICARE]
or
Office of Inspector General
Attn: OIG Hotline Operations
PO Box 23489
Washington, DC 20026
or
Phone: (800) 447-8477
TTY/TDD: (800) 377-4950
Fax (10 page max): (800) 223-8164
Health and Human Services Office of the Inspector General
Online: oig.hhs.gov/FRAUD/REPORT
Suspected fraud and abuse may also be reported to the state at:
Illinois State Police
Medicaid Fraud Control Unit
8151 W. 183rd Street, Suite F
Tinley Park, Illinois 60477
or
Phone: (844) 453-7283 [(844) ILFRAUD]
Illinois Attorney General
Online: hfs.illinois.gov/oig/reportfraud
Failure to report instances of suspected fraud, waste, and abuse is a violation of the law and subject to the penalties provided by law.
Please refer to Molina’s Provider Manuals for details about these Regulatory Requirements: