Members

Fraud and Abuse

fraud

Molina Healthcare’s Fraud, Waste and Abuse Plan benefits Molina, its employees, members, providers, payors and regulators by increasing efficiency, reducing waste, and improving the quality of services. Molina Healthcare takes the prevention, detection, and investigation of fraud, waste and abuse seriously, and complies with state and federal laws. Molina Healthcare investigates all suspected cases of fraud, waste and abuse and promptly reports all confirmed incidences to the appropriate government agencies. Molina Healthcare takes the appropriate disciplinary action, including but not limited to, termination of employment, termination of provider status, and/or termination of membership.

You can report potential fraud, waste and abuse without giving us your name. To report suspected Medicaid fraud, contact Molina Healthcare AlertLine at:

Toll free, 866-606-3889

or

Complete a report form online at:

https://www.molinahealthcare.alertline.com

You can also report to the state:

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at: 

https://apps.ahca.myflorida.com/inspectorgeneral/

If  you  report  suspected fraud and  your  report  results in  a  fine,  penalty  or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to twenty- five percent (25%) of the amount recovered, or a maximum of $500,000 per case (Section 409.9203, Florida Statutes).  You can talk to the Attorney General’s Office about keeping your identity confidential and protected.

Definitions:

 “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)

“Waste” means health care spending that can be eliminated without reducing the quality of care. Quality Waste includes, overuse, underuse, and ineffective use. Inefficiency Waste includes redundancy, delays, and unnecessary process complexity. For example: 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 the Medicaid/Medicare programs.

Here are some ways you can help stop fraud:

  • Do not give your Molina Healthcare ID card, Medical ID Card, or ID number to anyone other than a health care provider, a clinic, or hospital, and only when receiving care.
  • Never let anyone borrow your Molina Healthcare ID Card.
  • Never sign a blank insurance form.
  • Be careful about giving out your social security number.