Oncology & Radiology
Passport partners with New Century Health to administer cardiology and oncology services for members aged 18 and over. For clinical policies related to cardiology and oncology, please visit New Century’s website or click the following. Clinical policies are also housed within the Availity provider portal.
Pharmacy
MedImpact administers pharmacy benefits for Kentucky Medicaid Members. For information regarding Kentucky Medicaid Single PDL Prior Authorization Criteria please click .
Fraud Prevention Tips
Passport 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 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).
As defined in KRS 205.8451, “provider abuse” refers to practices by a health care provider that are inconsistent with sound fiscal, business or medical standards. These practices result in unnecessary costs to the Medical Assistance Program or lead to reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of care. It also includes practices that result in unnecessary cost to the Medical Assistance Program. "Recipient abuse" means, with reference to a medical assistance recipient, practices that result in unnecessary cost to the Medical Assistance Program or the obtaining of goods, equipment, medicines or services that are not medically necessary or that are excessive or constitute flagrant overuse or misuse of Medical Assistance Program benefits for which the recipient is covered.
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 themselves or some other person. It includes any act that constitutes fraud under applicable Federal or State Law (42 CFR § 455.2).
Under applicable federal law or KRS 205.8451-KRS205.8483, “fraud” means an intentional deception or misrepresentation made by a recipient or a provider with the knowledge that the deception could result in some unauthorized benefit to the recipient or provider or to some other person. It includes any act that constitutes fraud under applicable federal or state law.
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, 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.
Deficit Reduction Act
The Deficit Reduction Act (“DRA”) was signed into law in 2006. 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, like Passport, who receive or pay out at least $5 million in Medicaid funds per year, must comply with DRA. As a contractor doing business with Passport, providers and their staff have the same obligation to report any actual or suspected fraud, waste or abuse. Health care 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 members that are not medically necessary. |
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Making false statements to receive medical or pharmacy services. |
Balancing 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 member’s misuse of Passport health card. |
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Falsifying claims. |
Failure to report a member’s forgery/alteration of a prescription. |
Other Provider Crimes
Preventing Fraud and Abuse
Healthcare fraud is rising higher every year. Passport 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 and abuse:
Reporting Fraud and Abuse
You may report suspected cases of fraud and abuse to Passport’s Compliance Officer. You have the right to have your concerns reported anonymously to Passport, the Kentucky State Attorney General’s Medicaid Fraud Control Unit and/or The United States Office of Medicaid 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 Passport through one of the following:
Mail:
Attention: Compliance (CONFIDENTIAL)
Passport by Molina Healthcare
2028 W. Broadway
Louisville, KY 40203
Cabinet for Health and Family Services
Office of Inspector General
Division of Audits and Investigations
275 East Main Street, 5 E-D
Frankfort, KY 40621
Toll-Free: (800) 372-2970
Regulatory Requirements
Member Rights & Responsibilities
Below are the Passport rights and responsibilities as they are written in the Passport Member Handbook. Kentucky Law requires that health care providers or health care facilities recognize member rights while they are receiving medical care and that members respect the health care provider's or health care facility's right to expect certain behavior on the part of patients.
Passport Member Rights & Responsibilities Statement
Patient Safety
The Patient Safety Program identifies appropriate safety projects and error avoidance for Passport members in collaboration with their primary care providers.
Passport continues to support safe personal health practices for our members through our safety program, pharmaceutical management and case management/disease management programs and education. Passport monitors nationally recognized quality index ratings for facilities, including adverse events and hospital acquired conditions as part of a national strategy to improve health care quality mandated by the Patient Protection and Affordable Care Act (ACA). Health and Human Services (HHS) was created to identify areas that have the potential for improving health care quality to reduce the incidence of events.
*Printed copies of information posted on our website are available upon request.