Manuel du fournisseur

FRAUDE ET ABUS

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 : Tout type de tromperie intentionnelle ou de fausse déclaration faite en sachant que la tromperie pourrait entraîner un avantage non autorisé pour la personne qui l'a commise - ou toute autre personne. La tentative elle-même est une fraude, qu'elle réussisse ou non
  • Gaspillage : comprend la surutilisation des services ou d'autres pratiques qui, directement ou indirectement, entraînent des coûts inutiles. Le gaspillage n'est généralement pas considéré comme étant motivé par des actions intentionnelles, mais se produit plutôt lorsque les ressources sont mal utilisées.
  • Abus : Lorsque les prestataires de soins de santé ou les fournisseurs ne suivent pas les bonnes pratiques médicales, ce qui entraîne des coûts inutiles ou excessifs, un paiement incorrect, une mauvaise utilisation des codes ou des services qui ne sont pas médicalement nécessaires.

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/

Processus d'enquête

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.

Les politiques et les procédures

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 Valeur ajoutée, Carelon’s monthly provider newsletter.

Formations obligatoires

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 Page Web des formations des fournisseurs pour les dates de formation sur la fraude et les abus.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon Page Web sur la fraude et les abus. Tous les nouveaux fournisseurs doivent assister à l'un des nouveaux webinaires de formation sur la fraude et les abus offerts chaque trimestre. Vérifier la Page Web des formations des fournisseurs pour les dates disponibles.

Rapports

Tous les fournisseurs sont tenus de signaler les soupçons de fraude et d'abus. Si quelqu'un soupçonne qu'un membre ou un fournisseur (une personne qui reçoit des avantages) a commis une fraude, un gaspillage ou un abus, il a le droit de le signaler. Aucune personne qui signale des violations ou des soupçons de fraude et d'abus ne fera l'objet de représailles. Le nom de la personne signalant l'incident et son numéro de rappel seront gardés strictement confidentiels par les enquêteurs.

Signaler les préoccupations par :

  • Visiter lutter contre la fraude aux soins de santé. 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”
  • Services du fournisseur d'appels

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:

  • Facturation ou facturation des bénéficiaires de l'assistance médicale pour les services couverts
  • Facturation plusieurs fois pour le même service
  • Délivrance des médicaments génériques et facturation des médicaments de marque
  • Falsifying records
  • Prestation de services inappropriés ou inutiles

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