Manual del proveedor

FRAUDE Y ABUSO

The Department of Human Services (DHS) has mandated minimum requirements for Medical Assistance to ensure that Carelon and Carelon providers are preventing and detecting potential fraud, waste and abuse. 

  • Fraude: cualquier tipo de engaño o tergiversación intencional realizado con el conocimiento de que el engaño podría resultar en algún beneficio no autorizado para la persona que lo comete, o para cualquier otra persona. El intento en sí mismo es un fraude, independientemente de si tiene éxito o no.
  • Desperdicio: incluye el uso excesivo de servicios u otras prácticas que, directa o indirectamente, resultan en costos innecesarios. Por lo general, no se considera que el despilfarro se deba a acciones intencionales, sino que se produce cuando los recursos se utilizan indebidamente.
  • Abuso: cuando los proveedores o proveedores de atención médica no siguen las buenas prácticas médicas, lo que resulta en costos innecesarios o excesivos, pago incorrecto, uso indebido de códigos o servicios que no son médicamente necesarios.

In the Pennsylvania HealthChoices Behavioral Health Program Standards and Requirements, Appendix F obliges Carelon and Carelon providers to comply with Federal and State regulations and implement compliance programs and efforts that prevent and detect fraud, waste, and abuse. Subsequently, Carelon has implemented a compliance and program integrity plan with policies and procedures, trainings, and reporting responsibilities. The complete documentation for Carelon requirements are outlined on the Carelon Fraud and Abuse webpage available at the following address: http://pa.carelon.com/fraud-waste-and-abuse/

Proceso de investigación

The Special Investigations Unit (“SIU”) investigates suspected incidents of FWA for all types of services. Carelon may take corrective action with a Provider or Facility, which may include, but is not limited to:

  • Written warning and/or education: Carelon sends letters to the Provider or Facility advising the Provider or Facility of the issues and the need for improvement. Letters may include education or requests for repayment, or may advise of further action.
  • Medical record review: Carelon reviews medical records to investigate allegations or validate the appropriateness of Claims submissions.
  • Edits: A certified professional coder or investigator evaluates Claims and places payment or system edits in Carelon’s Claims processing system. This type of review prevents automatic Claims payments in specific situations.
  • Recoveries: Carelon recovers overpayments directly from the Provider or Facility. Failure of the Provider or Facility to return the overpayment may result in reduced payment for future Claims, termination from our network, or legal action.

Policias y procedimientos

Carelon has established policies and procedures to meet the DHS requirements specific to the prevention and detection of fraud, waste, and abuse (FWA). All Carelon providers are responsible to meet the requirements on the Carelon Fraud and Abuse webpage. Carelon will announce updates to or revisions to the Carelon Fraud and Abuse webpage in the Compliance Alert Section of Valor añadido, Carelon’s monthly provider newsletter.

Entrenamientos Obligatorios

All providers are required to have at least one representative attend an Annual Fraud and Abuse Training offered by Carelon. The provider or provider representative is responsible for reporting all information at the training to the provider and/or the entire staff of the provider agency. If a provider is unable to attend the Fraud and Abuse Training, the provider is responsible to independently review the mandatory training and document when the training is completed within their records. Check the Página web de Capacitaciones para proveedores para las fechas de capacitación sobre fraude y abuso.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon Página web de fraude y abuso. Todos los nuevos proveedores deben asistir a uno de los seminarios web de capacitación sobre fraude y abuso para nuevos proveedores que se ofrecen cada trimestre. Comprobar el Página web de Capacitaciones para proveedores para fechas disponibles.

Informes

Todos los proveedores están obligados a denunciar sospechas de fraude y abuso. Si alguien sospecha que algún Miembro o Proveedor (una persona que recibe beneficios) ha cometido fraude, desperdicio o abuso, tiene derecho a denunciarlo. Ninguna persona que denuncie infracciones o sospechas de fraude y abuso recibirá represalias por hacerlo. Los investigadores mantendrán en estricta confidencialidad el nombre de la persona que informa el incidente y su número de devolución de llamada.

Informar inquietudes por:

  • Visitando lucha contra el fraude en el cuidado de la salud. At the top of the page click “Report it” and complete the “Report Waste, Fraud and Abuse” form. For the “Who is the insurance company?” dropdown, select “Carelon”
  • Servicios del proveedor de llamadas

Any incident of fraud, waste or abuse may be reported to Carelon anonymously; however, Carelon’s ability to investigate an anonymously reported matter may be limited if Carelon doesn’t have enough information. Carelon encourages Providers and Facilities to give as much information as possible. Carelon appreciates referrals for suspected fraud, but be advised that Carelon does not routinely update individuals who make referrals as it may potentially compromise an investigation. Learn more at www.fighthealthcarefraud.com.

The Department of Human Services has established a hotline to report suspected fraud, waste, and abuse committed by any entity providing services to Medical Assistance recipients. The hotline number is 1-866-DHS-TIPS (1-844-347-8477) and is available between the hours of 8:30 AM and 3:30 PM, Monday through Friday. Voice mail is available at all other times. Callers do not have to give their name and may call after hours and leave a voice mail if they prefer.

Some common examples of fraud, waste and abuse are:

  • Facturar o cobrar a los beneficiarios de Asistencia Médica por los servicios cubiertos
  • Facturar más de una vez por el mismo servicio
  • Dispensación de medicamentos genéricos y facturación de medicamentos de marca
  • Falsifying records
  • Realizar servicios inapropiados o innecesarios

Suspected fraud, waste and abuse may also be reported via the website at: https://www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/MA-Fraud-and-Abuse—General-Information.aspx

You do not have to give your name if you use the website or email to report fraud, waste or abuse. The website contains additional information on reporting fraud, waste and abuse