Medicare Compliance

MEDICARE COMPLIANCE

MEDICARE COMPLIANCE


I AM A MERIDIANCARE MEMBER

I AM A MERIDIANCARE PROVIDER, VENDOR, BUSINESS PARTNER, OR SALES AGENT

 

I AM A MERIDIANCARE MEMBER

Each year, healthcare fraud costs taxpayers billions of dollars. It drives up the cost of health care and puts a burden on taxpayers and the healthcare system. Healthcare fraud can take on many forms, from small infractions to multi-million dollar schemes. It can also occur anywhere, from small rural towns to major metropolitan cities. 

How to Report Fraud
If you believe you have seen any of these activities, you can contact us immediately at 1-855-375-6725 (TTY 711), Monday - Sunday from 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 visit our FWA Reporting Site at http://mhplan.ethicspoint.com

Examples of Fraud
At MeridianCare, we are committed to doing our part to stop healthcare fraud. You can also do your part in fighting against healthcare fraud by protecting yourself against fraudulent claims and practices.

Here are some examples of activities you should look for: 

  • Does your Explanation of Benefits (EOB) show a charge that you did not receive?
  • Does your provider bill for services not provided?
  • Is your provider rendering unnecessary services?
  • Is your provider prescribing a higher quantity than is medically necessary for a condition?
  • Did a sales agent call you or show up at your residence without your permission to market a Medicare Advantage product or service?
  • Did you get a phone call from an unknown caller offering low cost or free medical services? Did the caller ask for your personal information, such as your Social Security number, Medicare number or date of birth?
  • Do you know someone who changed or forged a prescription?
  • Do you know a provider who primarily writes for narcotics or controlled substances?
  • Do you know someone who visits multiple doctors to get the same prescription?
  • Do you know someone who fills a prescription and then sells the medication?
  • Are medications you picked up expired, fake or diluted?
  • Did you pharmacy give you generics when your prescription requires that a brand be dispensed?
  • Does your pharmacist provide less than the prescribed quantity and bill for the full amount?
  • Did you incur a claim for prescriptions that you never picked up?

Resources 
There are many resources available to help you stay informed of fraudulent activities and give you tips on how to protect yourself from them. This is just a short list of some of these resources. 

 

Privacy Practices

MeridianCare Privacy Practices

 A Patient's Guide to the HIPAA Privacy Rule

 

I AM A MERIDIANCARE PROVIDER, VENDOR, BUSINESS PARTNER, OR SALES AGENT

Each year, healthcare fraud costs taxpayers billions of dollars. It drives up the cost of health care and puts a burden on taxpayers and the healthcare system. As an entity that does business with MeridianCare, you have a duty to prevent, detect and correct noncompliance and fraud, waste and abuse (FWA). 

Reporting 
If you suspect noncompliance or FWA activities, you must report them to your MeridianCare contract administrator. You may also report anonymously 24/7 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 http://mhplan.ethicspoint.com

Examples of Noncompliance and FWA 
Here are some common examples of noncompliant and FWA activities: 

Providers & Pharmacies: 

  • Submitting claims when you are on the Office of Inspector General's (OIG) exclusion list
  • Billing multiple payers for the same service, except as required for coordination of benefit
  • Inappropriate up-coding
  • Billing for services not rendered
  • Providing excessive or unnecessary services
  • Prescription forging or altering
  • Receiving illegal payments or other benefits to prescribe certain medications
  • Prescription drug shorting
  • Providing false or misleading information to justify coverage
  • Dispensing expired or adulterated prescription drugs
  • Illegal distribution of free samples
  • Billing for non-covered services as covered
  • Stolen prescriber Drug Enforcement Agency (DEA) number or prescription pad
  • Not meeting your contractual performance standards
  • Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule


Sales Agents: 

  • Using marketing materials not approved by MeridianCare or the Centers for Medicare and Medicaid (CMS)
  • Using high pressure sale tactics
  • Using deceptive and misleading sale tactics
  • Selling or marketing when you are not licensed or appointed
  • Making unsolicited contacts with beneficiaries
  • Not meeting your contractual performance standards
  • Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule


Administrative Business Partners: 

  • Doing Medicare work when you are on the Office of Inspector General's (OIG) exclusion list
  • Not meeting your contractual performance standards
  • Not providing annual compliance and FWA training to your employees
  • Not overseeing the work of your subcontractors


Compliance and FWA Training 

You and your employees are required to take the training annually. For your convenience, we have provided you with the following training materials.


You must ensure that all of your employees and any downstream entity (i.e., subcontractor) take this CMS-approved training module annually and read our Compliance Program & Standards of Conduct. All new employees and any downstream entity (i.e., subcontractor) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log to track your completion. 

If your employees have taken compliance training for other Medicare Advantage plans (through similar CMS-approved training modules) or through CMS' Medicare Learning Network (MLN) website, you do not have to re-take this training. However, you must still be familiar with our Compliance Program & Standards of Conduct, since they pertain to our company specifically. Also, if you are a medical provider and have met the most recent fraud, waste and abuse (FWA) certification requirements through enrollment into the Original Medicare program, as required by Medicare, you do not have to take Module I. FWA Training. However, they must still document their completion using the other health plan's Training Attendance Log or a modified version thereof. You do not need to send anything to us. However, your proof of training attendance and completion will be subject to audit and verification. 

 

Resources 
There are many resources available to help you stay informed of fraudulent activities and give you tips on how to protect yourself from them. This is just a short list of some of these resources. 

 

Privacy Practices

MeridianCare Privacy Practices

A Patient's Guide to the HIPAA Privacy Rule 

 

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)

.

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