FRAUD, WASTE, AND ABUSE

FRAUD, WASTE, AND ABUSE

FRAUD, WASTE, AND ABUSE


Health care Fraud, Waste and Abuse affects each and every one of us. It is estimated to account for 3-10% of the annual expenditures of health care in the United States. It is important for members and providers to know what health care Fraud, Waste and Abuse is, how to spot it and methods to report it.

Definitions of Fraud, Waste and Abuse

"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.

 

"Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicare 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 Medicare program.

 

"Waste" involves taxpayers not receiving reasonable value for money in connection with any government-funded activities due to an inappropriate act or omission by someone with control over or access to government resources. (e.g., executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight.

 

Some examples of Fraud, Waste and Abuse are:

 

  • A health care provider who bills for services that were never received
  • A supplier that bills for equipment or supplies that were never received
  • Someone uses another person's MeridianCare card to receive services covered by Medicare
  • A health care provider who bills for services more than once when only one service was provided
  • Someone alters a prescription that was written by their doctor
  • A health care provider or supplier that offers money or gifts as an incentive to receive healthcare services that are not medically necessary
  • Someone makes false statements to receive medical or pharmaceutical services

Reporting Fraud, Waste and Abuse

MeridianCare strongly encourages members and requires providers to report all cases of suspected Fraud, Waste and Abuse. If you know of any MeridianCare 

members, or providers, hospitals, or pharmacies who you suspect have committed Fraud, Waste or Abuse, you can report them using the process described below. You may report anonymously if you choose.


Reporting to MeridianComplete:

 

If you believe you have seen any Fraud, Waste or Abuse activities, you can contact us immediately at 1-855-580-1689 (TTY 711), Monday – Sunday, 8 a.m. to 8 p.m. We will conduct a thorough investigation and work with State and Federal government agencies to make sure your rights and services are protected to the fullest extent.

 

You may also report anonymously 24 hours a day 7 days a week at 1-855-375-6725 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m. You may also visit our FWA Reporting Site at mhplan.ethicspoint.com.

 

Reporting to the Inspector General:

 

Illinois State Police

Medicaid Fraud Control Unit

801 South Seventh Street – Suite 500A

Springfield , IL 62703

Phone: 888-557-9503

Report Fraud Online

 

U.S. Department of Health and Human Services Office of Inspector General (OIG)

Phone:1-800-HHS-TIPS (447-8477)

Fax: 1-800-223-8164

TTY: 1-800-377-4950

Address: US Department of Health and Human Services Office of Inspector General

ATTN: OIG HOTLINE OPERATIONS

PO Box 23489

Washington, DC 20026

False Claims Act

The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the Government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government's damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud. 


The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit on behalf of the Government against the person or business that committed the fraud. The lawsuit is known as a "qui tam" case, but it is more commonly referred to as a "whistleblower" case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer. 

For more information on the False Claims Act, please contact the Meridian 

Corporate Compliance Officer at 

1-855-580-1689 (TTY 711), Monday - Sunday from 8 a.m. – 8 p.m.

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MEDICARE DISCLAIMER

MeridianComplete is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees.

 

You can get this document in Spanish, or speak with someone about this information in other languages for free. Call

1-855-580-1689 (TTY users should call 711)

,

Monday - Sunday, 8 a.m. to 8 p.m.

  The call is free.

 

Usted puede obtener gratuitamente este documento en español o hablar con alguien sobre esta información en otros idiomas. Llame al

1-855-580-1689

(los usuarios de TTY deben llamar al 711), lunes a domingo, de 8 a.m. a 8 p.m. La llamada es gratuita.

 

Limitations, copays, and restrictions may apply. For more information, call MeridianComplete Member Services or read the MeridianComplete Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

 

Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

 

For certain kinds of drugs, you can use the plan’s network mail-order services. We also have an optional automatic mail-order delivery program under which we will automatically fill all new prescriptions your health care provider sends to us, as well as refills for prescriptions that have already been filled but are running out. Usually a mail-order pharmacy order will get to you in no more than 5 days. If you experience any problems receiving your mail order prescription, call Member Services at

1-855-580-1689 (TTY users should call 711)

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Page Last Modified: 11/20/2017 2:43:27 PM