PREVENTING FRAUD, ABUSE, AND WASTE OF MEDICAID AND OTHER INSURANCE

Most of the services Mains’l provides are funded by Medicaid (also known as Medi-Cal in California). So, you play a vital role in protecting the integrity of the Medicaid Program. To reduce waste, abuse, and fraud you need to know what to watch for and when to report if you suspect that waste, abuse, or fraud is occurring.

Although the terms Medicaid and Medicare fraud and abuse have slightly different meanings, depending on individual state law, they generally mean the same thing: any violations of the state and federal requirements related to the delivery of services to Medicaid or Medicare recipients. 
Waste is a broad term that refers to care that is not effective or that is not delivered efficiently.

Abuse is when a provider does not follow good medical practices, resulting in unnecessary costs, improper payment, or services that are not medically necessary. 
Fraud is when Medicaid or other insurance is billed for services or supplies a person who uses services never received.  It is when a person knowingly cheats or is dishonest.  The dishonesty results in a benefit such as payment or coverage that the person would not have been entitled to otherwise.

Examples of Fraud, Abuse and Waste include but are not limited to:

• Using the wrong billing code.    
• Buying too many goods or supplies.    
• Providing more services than a person needs.
• Buying excessive goods or supplies that aren’t needed or used on a regular basis.    
• Submitting a timesheet with time you did not work.
• Using or taking goods or services from the intended recipient.

Multiple state and federal laws make it illegal for a person to bill Medicaid, Medicare or other insurance providers for goods or services that he or she knows are false.  

Any person who submits a claim to Mains’l that he or she knows, or should know is false will be held responsible and his or her action may be punishable by law. 

Suspected fraud, abuse, and violations of this policy must be immediately reported. Any report of fraud or abuse, received by Mains’l will be investigated. Suspected waste should also be reported to reduce or prevent waste from continuing. 

Failure of an employee to report suspected fraud, abuse or a violation of this policy will result in employee discipline, up to and including separation.