Members

Fraud and Abuse

fraud

Affinity by Molina Healthcare’s Fraud, Waste and Abuse Plan benefits Affinity, its employees, members, providers, payors and regulators by increasing efficiency, reducing waste, and improving the quality of services. Affinity takes the prevention, detection, and investigation of fraud, waste and abuse seriously, and complies with state and federal laws. Affinity investigates all suspected cases of fraud, waste and abuse and promptly reports all confirmed incidences to the appropriate government agencies. Affinity 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 (TTY/TDD: 711)

or

Complete a report form online at:

https://molinahealthcare.alertline.com

You may also send your concerns by mail to:

Attention: Compliance Officer
(CONFIDENTIAL)
Molina Healthcare of New York, Inc.
2900 Exterior Street
Suite 202
Bronx, New York 10463

You can also report to the state:

To report suspected Medicaid fraud and/or abuse in New York state, call New York State Attorney General's Medicaid Fraud Control Unit toll free (800) 771-7751 or complete a Medicaid Fraud and Abuse Comment Form, which is available online at:

https://ag.ny.gov/comments-mfcu

or you may also:

Call the Office of the Medicaid Inspector General (OMIG) Fraud Hotline toll free: (877) 87FRAUD or (877) 873-7283
or file an allegation online at: www.omig.ny.gov/fraud/file-an-allegation

You may also complete the form and mail it to:

NYS OMIG Bureau of Fraud Allegations
800 North Pearl Street
Albany, NY 12204
or fax the form to: (518) 408-0480

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. The reward may be up to = 30% of the amount recovered, (Section 31 U.S.C. § 3730(d), New York False Claims Act Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential and protected. For more information, contact the New York State Attorney Generals office toll free, (800) 771-7755.

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 programs.

Here are some ways you can help stop fraud:

  • Do not give your Affinity 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 Affinity Healthcare ID Card.
  • Never sign a blank insurance form.
  • Be careful about giving out your social security number.