راهنمای ارائه دهنده

تقلب و سوء استفاده

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. 

  • تقلب: هر نوع فریب عمدی یا ارائه نادرست با آگاهی از این که فریب ممکن است منجر به منافع غیرمجاز برای شخص مرتکب آن یا هر شخص دیگری شود. تلاش به خودی خود تقلب است، صرف نظر از موفقیت یا عدم موفقیت آن
  • ضایعات: شامل استفاده بیش از حد از خدمات یا سایر اعمالی است که به طور مستقیم یا غیرمستقیم منجر به هزینه های غیر ضروری می شود. ضایعات عموماً ناشی از اقدامات عمدی در نظر گرفته نمی‌شوند، بلکه زمانی اتفاق می‌افتند که از منابع سوء استفاده می‌شود.
  • سوء استفاده: هنگامی که ارائه دهندگان یا تامین کنندگان مراقبت های بهداشتی از اقدامات پزشکی خوب پیروی نمی کنند که منجر به هزینه های غیرضروری یا بیش از حد، پرداخت نادرست، سوء استفاده از کدها یا خدماتی می شود که از نظر پزشکی ضروری نیستند.

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/

فرآیند تحقیق

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.

سیاستها و روندها

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 ارزش افزوده, Carelon’s monthly provider newsletter.

آموزش های اجباری

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 صفحه وب آموزش های ارائه دهنده برای تاریخ های آموزش کلاهبرداری و سوء استفاده.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon صفحه وب تقلب و سوء استفاده. همه ارائه دهندگان جدید باید در یکی از وبینارهای آموزشی تقلب و سوء استفاده از ارائه دهندگان جدید که هر فصل ارائه می شود، شرکت کنند. بررسی کنید صفحه وب آموزش های ارائه دهنده برای تاریخ های موجود

گزارش نویسی

همه ارائه دهندگان موظفند تقلب و سوء استفاده مشکوک را گزارش کنند. اگر کسی مشکوک باشد که یکی از اعضا یا ارائه‌دهنده‌ها (شخصی که مزایای دریافت می‌کند) مرتکب تقلب، اتلاف یا سوءاستفاده شده است، حق دارد آن را گزارش کند. هیچ فردی که تخلفات یا مشکوک به کلاهبرداری و سوء استفاده را گزارش کند به دلیل انجام این کار انتقام نخواهد گرفت. نام شخص گزارش‌دهنده حادثه و شماره تماس وی توسط بازرسان محرمانه نگه داشته می‌شود.

گزارش نگرانی توسط:

  • بازدید fighthealthcarefraud.com. 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”
  • تماس با ارائه دهنده خدمات

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:

  • صورت‌حساب یا هزینه دریافت‌کنندگان کمک پزشکی برای خدمات تحت پوشش
  • صدور صورت حساب بیش از یک بار برای یک سرویس
  • توزیع داروهای ژنریک و صدور صورت حساب برای داروهای نام تجاری
  • Falsifying records
  • انجام خدمات نامناسب یا غیر ضروری

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