Fraud, waste and abuse in Massachusetts
Compliance is everyone’s responsibility at Senior Whole Health, LLC, dba Molina Healthcare, supporting honest communication, safety and trust in line 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 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).
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, 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
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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 patient’s misuse of Molina ID card. |
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Falsifying claims. |
Failure to report a patient's forgery/alteration of a prescription. |
Other provider crimes
Preventing fraud and abuse
Health care fraud is rising 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 healthcare fraud and abuse:
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 Massachusetts 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. 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 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 online, visit Molina Healthcare Alertline.
4). To report an issue by mail, please direct your inquiry to:
Attn: Compliance Officer (CONFIDENTIAL)
Molina Healthcare
200 Oceangate, Suite 100
Long Beach, CA 90802.
Regulatory requirements