Manual do Provedor

FRAUDE E 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: Qualquer tipo de engano intencional ou deturpação feito com o conhecimento de que o engano poderia resultar em algum benefício não autorizado para a pessoa que o cometeu – ou qualquer outra pessoa. A tentativa em si é fraude, independentemente de ser ou não bem-sucedida
  • Desperdício: inclui o uso excessivo de serviços ou outras práticas que, direta ou indiretamente, resultam em custos desnecessários. Desperdício geralmente não é considerado causado por ações intencionais, mas ocorre quando os recursos são mal utilizados.
  • Abuso: quando os provedores ou fornecedores de serviços de saúde não seguem boas práticas médicas, resultando em custos desnecessários ou excessivos, pagamento incorreto, uso indevido de códigos ou serviços que não são clinicamente necessários.

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/

Processo Investigativo

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.

Políticas e procedimentos

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 adicionado, Carelon’s monthly provider newsletter.

Treinamentos obrigatórios

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 de treinamento de provedores para datas de treinamento de fraude e abuso.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon Página de fraude e abuso. Todos os novos provedores devem participar de um dos Webinars de treinamento sobre fraude e abuso de novos provedores oferecidos a cada trimestre. Verifica a Página de treinamento de provedores para datas disponíveis.

Comunicando

Todos os provedores são obrigados a relatar suspeitas de fraude e abuso. Se alguém suspeitar que algum Membro ou Provedor (uma pessoa que recebe benefícios) cometeu fraude, desperdício ou abuso, ele tem o direito de denunciá-lo. Nenhum indivíduo que denuncie violações ou suspeita de fraude e abuso sofrerá retaliação por fazê-lo. O nome da pessoa que relatou o incidente e seu número de retorno serão mantidos em sigilo absoluto pelos investigadores.

Relatar preocupações por:

  • visitando 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”
  • Serviços do Provedor de Chamadas

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:

  • Faturamento ou cobrança de destinatários de Assistência Médica por serviços cobertos
  • Faturamento mais de uma vez pelo mesmo serviço
  • Distribuição de medicamentos genéricos e cobrança de medicamentos de marca
  • Falsifying records
  • Execução de serviços inadequados ou desnecessários

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