Molina Complete Care 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.
"Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program 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 the Medicaid program. (42 CFR §455.2) "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. (42 CFR § 455.2).
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 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:
- 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.
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 Molina, who 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 fraud, waste or abuse. Health care entities must have written policies that inform employees, contractors, and agents of the following:
- The Federal False Claims Act and state laws pertaining to submitting false claims;
- How providers will detect and prevent fraud, waste, and abuse;
- Employee protected rights as whistleblowers.
The Federal False Claims Act and the Medicaid False Claims Act have qui tam language commonly referred to as “whistleblower” provisions. These provisions encourage employees (current or former) and others to report instances of fraud, waste or abuse to the government. The government may then proceed to file a lawsuit against the organization/individual accused of violating the False Claims acts. The whistleblower may also file a lawsuit on their own. Cases found in favor of the government will result in the whistleblower receiving a portion of the amount awarded to the government.
The Federal False Claims Act and the Medicaid False Claims Act contain some overlapping language related to personal liability. For instance, the Medicaid False Claims Act has the following triggers:
- Presents or causes to be presented to the state a Medicaid claim for payment where the person receiving the benefit or payment is not authorized or eligible to receive it;
- Knowingly applies for and receives a Medicaid benefit or payment on behalf of another person, except pursuant to a lawful assignment of benefits, and converts that benefit or payment to their own personal use;
- Knowingly makes a false statement or misrepresentation of material fact concerning the conditions or operation of a health care facility in order that the facility may qualify for certification or recertification required by the Medicaid program;
- Knowingly makes a claim under the Medicaid program for a service or product that was not provided.
Whistleblower protections state that employees who have been discharged, demoted, suspended, threatened, harassed or otherwise discriminated against due to their role in furthering a false claim are entitled to all relief necessary to make the employee whole including:
- Employment reinstatement at the same level of seniority
- Two times the amount of back pay plus interest
- Compensation for special damages incurred by the employee as a result of the employer’s inappropriate actions.
Affected entities who fail to comply with the law will be at risk of forfeiting all Medicaid payments until compliance is met. MCC will take steps to monitor MCC contracted providers to ensure compliance with the DRA.
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 and Abuse
|By a Member
||By a Provider
- Lending an ID card to someone who is not entitled to it
- Altering the quantity or number of refills on a prescription
- Making false statements to receive medical or pharmacy services
- Using someone else’s insurance card
- Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect information to receive benefits
- Pretending to be someone else to receive services
- Falsifying claims
- Billing for services, procedures and/or supplies that have not actually been rendered
- Providing services to patients that are not medically necessary
- Balancing Billing a Medicaid member for Medicaid covered services
- Double billing or improper coding of medical claims
- 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
- Concealing patients misuse of Molina Complete Care card
- Failure to report a patient’s forgery/alteration of a prescription
Other Provider Schemes
- Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients
- A physician knowingly and willfully referring Medicare or Medicaid patients to health care facilities in which or with which the physician has a financial relationship (The Stark Law)
- Balance billing—asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider's usual and customary fees
Preventing Fraud and Abuse
MCC and other State and Federal regulatory and law enforcement agencies are working together to help prevent fraud, waste, and abuse. Here are a few helpful prevention tips:
- Do not give your MCC ID card or number to anyone except your doctor, clinic, hospital or other health care provider.
- Do not let anyone borrow your MCC 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 MCC ID card is lost or stolen, report it to MCC immediately.
Reporting Fraud, Waste, and Abuse
MCC expects providers and their staff and agents to report any suspected cases of fraud, waste or abuse. MCC will not retaliate against a provider who informs MCC, the federal government, state government or any other regulatory agency with oversight authority of any suspected cases of fraud, waste or abuse.
MCC has the responsibility to assess the merits of any allegation of fraud, waste, or abuse. MCC will coordinate and fully cooperate and assist DMAS and any other state or federal agency in identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste. MCC will provide records and information, as requested.
You can report suspected fraud, waste and abuse to MCC by the following methods:
Molina AlertLine: 1-866-606-3889
We accept reports to the Corporate Compliance Hotline 24 hours a day/seven days a week. The hotline is maintained by an outside vendor. Callers may choose to remain anonymous. All calls will be investigated and remain confidential.
In addition to reporting suspected fraud, waste, or abuse to MCC, you can report to these other agencies:
Department of Medical Assistance Services Fraud Hotline
Phone: (800) 371-0824 or (866) 486-1971 or (804) 786-1066
Virginia Medicaid Fraud Control Unit (Office of the Attorney General)
Fax: (804) 786-3509
Mail: Office of the Attorney General
Medicaid Fraud Control Unit
202 North Ninth Street
Richmond, VA 23219
Virginia Office of the State Inspector General Fraud, Waste, and Abuse Hotline
Phone: (800) 723-1615
Fax: (804) 371-0165
Mail: State FWA Hotline
101 N. 14th Street
The James Monroe Building 7th Floor
Richmond, VA 23219
You can also contact the U.S. Department of Health & Human Services Office of Inspector General at:
Office of Inspector General Department of Health & Human Services
P.O. Box 23489
Washington, DC 20026
Phone: 1-800-HHS-TIPS (TTY 1-800-377-4950)
To report suspected recipient fraud to DMAS, contact:
Department of Medical Assistance Services
Recipient Audit Unit
600 East Broad Street, Suite 1300
Richmond, VA 23219
Phone: (800) 371-0824
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.
For more information on fraud, waste and abuse, refer to your provider manual.