提供者手册

欺诈和滥用

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. 

• 欺诈：任何类型的故意欺骗或虚假陈述，明知欺骗可能会给实施欺骗的人或任何其他人带来一些未经授权的利益。尝试本身就是欺诈，无论成功与否
• 浪费：包括过度使用服务或其他直接或间接导致不必要成本的做法。浪费通常不被认为是由故意行为驱动的，而是在资源被滥用时发生。
• 滥用：当医疗保健提供者或供应商不遵循良好的医疗实践，导致不必要或过高的费用、不正确的付款、滥用代码或非医疗必需的服务时。

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/

调查过程

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.

政策和程序

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 增值, Carelon’s monthly provider newsletter.

强制性培训

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 提供者培训网页 欺诈和滥用培训日期。

All new providers are responsible to complete and review the documentation and previous trainings available on the Carelon 欺诈和滥用网页。所有新提供者都必须参加每个季度提供的新提供者欺诈和滥用培训网络研讨会之一。检查 提供者培训网页 有关可用日期。

报告中

所有提供商都必须报告可疑的欺诈和滥用行为。如果有人怀疑任何会员或提供者（领取福利的人）犯有欺诈、浪费或滥用行为，他们有权举报。举报违规或涉嫌欺诈和滥用行为的任何个人都不会因此而受到报复。调查人员将对事件报告人的姓名及其回电号码严格保密。

通过以下方式报告问题：

• 参观 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”
• 呼叫提供者服务

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:

• 为承保服务的医疗援助接收者计费或收费
• 为同一服务多次计费
• 分配仿制药并为品牌药计费
• Falsifying records
• 提供不适当或不必要的服务

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