Fraud, Waste, and Abuse Prevention
Molina Healthcare of California ("Molina") 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 practices that are inconsistent with sound fiscal, business or medical practices that result in an unnecessary cost to the Medicaid/Medicare programs or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid/Medicare programs. (42 CFR 455.2 and as further defined in Welf. & Inst. Code Section 14043.1 (a).)
"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 himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 455.2 W. & I. Code Section14043.1(i).)
"Waste" is health care spending that can be eliminated without reducing the quality of care.
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:
- 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.
Health care fraud is:
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, Waste, and Abuse
| By a Member | By a Provider |
|---|---|
| Using someone else’s insurance card | False coding, altering records, or claims |
| Altering or forging a prescription | Billing for services not rendered or goods not provided |
| Knowingly enrolling someone not eligible for coverage under their policy or group coverage | Billing separately for services that should be a single service |
| Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits | Billing for services not medically necessary |
| Altering the billed amount for services. Altering the service date | Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis |
| Unbundling of procedures | |
| Upcoding |
Other Provider Crimes
- 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
Healthcare fraud is rising higher and higher 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:
- Do not give your Molina ID card or number to anyone except your doctor, clinic, hospital or other healthcare provider.
- Do not let anyone borrow your Molina 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 Molina ID card is lost or stolen, report it to Molina immediately.
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 California 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:
- Nature of complaint
- The names of individuals and/or entity involved in suspected fraud and/or abuse including address, phone number, Medicaid ID number and any other identifying information
You may report fraud and abuse to Molina Healthcare through one of the following:
Telephone
The Molina Healthcare AlertLine is available 24/7. It can be reached at any time (day or night,) over the weekend, or even on holidays. To report an issue by telephone, call the toll-free at (866) 606-3889.
Online
To report an issue online, visit: https://molinahealthcare.AlertLine.com.
Regular Mail
Write (marked confidential) to: Compliance Officer, Molina Healthcare of California, 200 Oceangate, Suite 100, Long Beach, CA 90802.
You may report fraud and abuse to the California Department of Health Care Services or United States Office of Inspector General by:
- Calling the toll-free number of the Department of Health Care Services Anti-Fraud Line: (800) 822-6222 or sending an e-mail to: stopmedicalfraud@dhcs.ca.gov
- Calling the toll-free number of the Office of Inspector General: (800) 447-8477
Additional Health Care Compliance and Anti-Fraud & Abuse Information may be accessed by visiting any of the following websites:
Centers for Medicare & Medicaid Services
(Information Relative to the Medicare Program and National Health Care Laws) 90 7th Street, Suite 5–300 (5W), San Francisco, CA 94103-6707
http://cms.gov/
Department of Managed Health Care
California HMO Help Center 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 Phone: (888) 466-2219
http://www.dmhc.ca.gov/
Office of the Inspector General (HCFA-OIG)
OIG List of Excluded Individuals (Listing of Health Care Providers who've been excluded form Federal Participation) P.O. Box 23489, Washington, DC 20026 HHS TIPS Fraud Hotline: (800) HHS-TIPS
http://www.oig.hhs.gov/
Medi-Cal/California Department of Health Care Services
(Information regarding Medi-Cal & State Licensing of Facilities) P.O. Box 997413, MS 4400, Sacramento, CA 95899-7413
Department of Health Care Services Anti-Fraud Line: (800) 822-6222
Email: stopmedicalfraud@dhcs.ca.gov