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

Submitted by admin on Fri, 04/30/2021 - 12:30
Policy: 

Most of the services Mains’l provides are funded by Medicaid. 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 client 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:

 

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 is 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.

 

 

Procedure: 

Any suspicions of fraud, abuse, and waste should be directly reported to our Public Funds Compliance Officer, the Director of Administration.

The Public Funds Compliance Officer will conduct an internal investigation. In the event that our Public Funds Compliance Officer, the Director Administration is suspected or alleged to be involved in fraud, the National Director of Human Resources will complete the investigation. The investigation will include at least the following:

  1. Whether fraud, abuse, or waste occurred;
  2. Whether written policies and procedures were adequate;
  3. Whether written policies and procedures were followed;
  4. Whether there is a need for additional staff training;
  5. Whether there is a need for external reporting.

If it is determined after a thorough investigation that any employee has committed fraud, their employment will be terminated immediately.

If it is determined that a vendor, person receiving services, or other business partner has committed fraud, Mains’l reserves the right to end the relationship.

While Mains’l prefers that reports of suspected fraud and abuse are made internally, you have the right to report suspicions of Medicaid abuse or fraud to a state agency.

In California:      Department of Health Care Services/Health Care Programs at 800-822-6222 or

http://www.dhcs.ca.gov/individuals/pages/stopmedi-calfraud.aspx

Office of the Attorney General 800-722-0432

http://www.ag.ca.gov/bmfea/medical.htm

In Minnesota:    Department of Human Services Provider Fraud: 800-657-3750 Recipient Fraud: 800-627-9977

http://mn.gov/dhs/general-public/licensing/report-fraud/index.jsp

Mains’l will not discharge, discipline, threaten, or discriminate against, or penalize an employee, who in good faith reports or participates in an investigation of fraud, abuse, or waste internally or externally. However, failure to report suspicions of fraud, abuse, and waste will result in disciplinary action, up to and including termination.

(Rev.5/24/2019 CJ)