プロバイダーマニュアル

詐欺と悪用

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. 

• 詐欺: 意図的な欺瞞または虚偽の表示で、その欺瞞が、それを実行した人物またはその他の人物に無許可の利益をもたらす可能性があることを認識した上で行われます。成功するかどうかに関係なく、その試み自体が不正行為です
• 無駄: サービスの過剰使用や、直接的または間接的に不必要なコストが発生するその他の慣行が含まれます。廃棄物は一般に、意図的な行動によって引き起こされるとは考えられていませんが、リソースが誤用されたときに発生します。
• 乱用: 医療提供者またはサプライヤーが適切な医療慣行に従わず、不必要または過剰な費用、不正確な支払い、コードの誤用、または医学的に必要のないサービスを提供する場合。

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/

調査プロセス

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.

ポリシーと手順

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 付加価値, Carelon’s monthly provider newsletter.

必須トレーニング

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 プロバイダートレーニングのウェブページ 不正行為および虐待に関するトレーニングの日程。

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon 詐欺と悪用のウェブページ.すべての新規プロバイダーは、四半期ごとに提供される新規プロバイダー詐欺および不正使用トレーニング Webinar のいずれかに参加する必要があります。を確認してください プロバイダートレーニングのウェブページ 利用可能な日付。

報告

すべてのプロバイダーは、疑わしい詐欺や悪用を報告する必要があります。メンバーまたはプロバイダー (利益を受け取る人) が詐欺、浪費、または虐待を犯した疑いがある場合、彼らはそれを報告する権利を有します。違反や不正行為や虐待の疑いを報告した個人は、報復を受けることはありません。インシデントを報告した人物の名前とコールバック番号は、捜査官によって厳重に守られます。

懸念を報告する方法:

• 訪問 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”
• プロバイダー サービスの呼び出し

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:

• 対象サービスの医療支援受領者への請求または課金
• 同じサービスに対して複数回請求する
• ジェネリック医薬品の調剤と先発医薬品の請求
• Falsifying records
• 不適切または不必要なサービスの実行

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