Children’s Community Health Plan is required to cooperate with regulatory and law enforcement agencies in reporting any activity that appears to be suspicious in nature. According to the law, any information that we have concerning such matters must be turned over to the appropriate governmental agencies.
- Fraud is defined as intentional deception or misrepresentation made by an entity or person, including but not limited to a subcontractor, vendor, provider, member, or other customer with the knowledge that the deception could result in some unauthorized benefit to a person or an entity.
Fraud includes any attempt to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by or under the custody or control of, any health care benefit program. It includes any act that constitutes fraud under applicable state and federal laws. For example, fraud may exist when a provider bills for services not rendered, and the service cannot be substantiated by documentation.
- Waste is defined as an act involving payment or the attempt to obtain payment for items or services where there was no intent to deceive or misrepresent, but where the outcome of poor or inefficient methods resulted in unnecessary costs to the plan.
- Abuse is defined as incidents or practices that are inconsistent with accepted, sound business, fiscal, or medical administrative practices. Abuse may, directly or indirectly, result in unnecessary costs to the health plan, improper payment, or payment for services that fail to meet professional standards of care or are medically unnecessary.
Abuse consists of payment for items or services when there is no legal entitlement and the recipient has knowingly misrepresented the facts to receive the benefit or payment. Abuse often takes the form of claims for services not medically necessary or not medically necessary to the extent provided. Abuse also includes practices by subcontractors, providers, members, or customers that result in unnecessary costs to the health plan. For example, abuse may exist when the provider fails to appropriately bill new and established patient office codes. The provider bills a “new” patient code both on the initial visit and subsequent visits.
More fraud, waste, and abuse examples, include but are not limited to:
- Submitting false or misleading information about services performed
- Misrepresenting the services performed (e.g., up-coding to increase reimbursement)
- Retaining and failing to refund and report overpayments (e.g., if your claim was overpaid, you are required to report and refund the overpayment, and unpaid overpayments also are grounds for program exclusion)
- A claim that includes items or services resulting from a violation of the Anti-Kickback Statute now constitutes a false or fraudulent claim under the False Claims Act
- Treating all patients weekly regardless of medical necessity
- Inserting a diagnosis code not obtained from a physician or other authorized individual
- Submitting claims for services ordered by a provider that has been excluded from participating in federally and/or state-funded health care programs
- Lying about credentials, such as degree and licensure
How to Report Fraud, Waste, and Abuse
Contact the Children’s Community Health Plan Special Investigations Unit online compliance reporting at ethicspoint.com, and click on:
- “File a New Report via Ethicspoint”, then “Submit”
- “CCHP”, then “Submit”
- You will be directed on how to file the report
You can also report:
- Anonymously at 877-659-5200
- By visiting CMS’ State Contacts Database
- By calling the Office of Inspector General’s (OIG) National Fraud Hotline at 800-HHS-TIPS