Manwal ng Tagabigay

PANLOLOKO AT 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. 

  • Panloloko: Anumang uri ng sinadyang panlilinlang o maling representasyon na ginawa sa kaalaman na ang panlilinlang ay maaaring magresulta sa ilang hindi awtorisadong benepisyo sa taong gumawa nito - o sinumang ibang tao. Ang pagtatangka mismo ay panloloko, hindi alintana kung ito ay matagumpay o hindi
  • Basura: Kabilang ang labis na paggamit ng mga serbisyo, o iba pang mga kasanayan na, direkta o hindi direkta, ay nagreresulta sa mga hindi kinakailangang gastos. Ang basura ay karaniwang hindi itinuturing na hinihimok ng mga sinadyang aksyon, ngunit sa halip ay nangyayari kapag ang mga mapagkukunan ay maling ginagamit.
  • Pang-aabuso: Kapag ang mga tagapagbigay ng pangangalagang pangkalusugan o mga tagapagtustos ay hindi sumunod sa mahusay na mga medikal na kasanayan na nagreresulta sa hindi kailangan o labis na mga gastos, maling pagbabayad, maling paggamit ng mga code, o mga serbisyo na hindi medikal na kinakailangan.

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/

Proseso ng Pagsisiyasat

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.

Mga Patakaran at Pamamaraan

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 Karagdagang halaga, Carelon’s monthly provider newsletter.

Mga Mandatoryong Pagsasanay

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 Webpage ng Provider Trainings para sa mga petsa ng Pagsasanay sa Panloloko at Pang-aabuso.

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon Fraud at Abuse webpage. Ang lahat ng mga bagong provider ay dapat dumalo sa isa sa mga Webinar ng Bagong Pagsasanay sa Panloloko at Pang-aabuso sa Bagong Provider na iniaalok sa bawat quarter. Suriin ang Webpage ng Provider Trainings para sa mga available na petsa.

Pag-uulat

Ang lahat ng mga provider ay kinakailangang mag-ulat ng pinaghihinalaang panloloko at pang-aabuso. Kung may pinaghihinalaan na sinumang Miyembro o Provider (isang taong tumatanggap ng mga benepisyo) ay nakagawa ng panloloko, pag-aaksaya o pang-aabuso, may karapatan silang iulat ito. Walang indibidwal na nag-uulat ng mga paglabag o pinaghihinalaang panloloko at pang-aabuso ang gagantihan sa paggawa nito. Ang pangalan ng taong nag-uulat ng insidente at ang kanyang callback na numero ay pananatilihing mahigpit na kumpiyansa ng mga imbestigador.

Mag-ulat ng mga alalahanin sa pamamagitan ng:

  • Pagbisita 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”
  • Pagtawag sa Mga Serbisyo ng Provider

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:

  • Pagsingil o pagsingil sa mga tumatanggap ng Tulong na Medikal para sa mga sakop na serbisyo
  • Pagsingil nang higit sa isang beses para sa parehong serbisyo
  • Pagbibigay ng mga generic na gamot at pagsingil para sa mga brand name na gamot
  • Falsifying records
  • Gumaganap ng hindi naaangkop o hindi kinakailangang mga serbisyo

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