MOLINA HEALTHCARE Polic:y and Procedure No. C 08 of Utah Effective Date: November 2003 Reviewed and Revised Ollie: 2/6/08; 2/25/0S; 11 /5/0S; II/ IS/OS, 3/4/09, 6/9/09, S/31 / 1O Amy Bingham, Compliance Director Reviewed Only Date: 6/05,1/31/2011, 1/24/2012 Supersedes and replaces: "CC-02 - Anti- Signature: ()j" A' ~';A~, Fraud and Abuse Workgroup"; "CC-03 - V -0 Fraud and Abuse Prevention MHU"; and "C- OMe: 01 - Anti-Fraud Plan" 4/Q/I'l- I. PURPOSE Date: 2/14/0S; 2/25/0S; 11 /5/0S To establish a healthcarc fraud and abuse prevention plan for the detection. investigation and reporting of suspected healtheare related fraud and abuse in order to reduce inappropriate costs and protect consumers II. POLICY The Compliance Department shall establish and implement a fraud and abuse prevention plan. Appropriate Molina I-Iealthcare of Utah (Molina Healthcare) employees, providers and members will be instructed on methods to detect healthcare related fraud and abuse. The Compliance Department shall require Ihal all reported instances of suspected fra ud and abuse are appropriately investigated. Verified instances of health care related fraud and abuse shall be reported to the proper authorities. Healthcare Related Fraud and Abuse are defined as follows: A. Fraud: Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CfR 455,2), 8. Abuse: Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary east to the Medicaid program. or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized Page I 01'6
III. PROCEDURE A. The Compliance Department shall oversee and respond to inquiries related to the fraud and abuse prevention plan. B. The Compliance Department shall provide regular education to all appropriate employees, members and providers concerning the detection and prevention of healthcare related fraud and abuse. The education shall include, but not be limited to, the following areas: 1. Claims Department personnel shall be instructed in the detection of fraudulent claims filings. 2. Utilization Review personnel shall be instructed in the detection of both underutilization and over-utilization of health care services by providers. C. Potential indicators of fraudulent or abusive healthcare activities are included, but not limited to the list in Attachment A. The Compliance Department shall inform all employees of their duty to report suspected health-related fraud and abuse to their Supervisor or the Compliance Department and their ability to make such reports on a confidential or anonymous basis. Suspected fraud and abuse can also be reported to the appropriate regulatory agency. D. The following information is helpful when reporting suspected health-related fraud and abuse: 1. Nature of the complaint and timeframe of the event(s). 2. Name of the individual(s) and/or entity involved in the suspected fraud and/or abuse, including address, phone number, and Medicaid identification number. E. When reports of suspected fraudulent acts are received, they will be promptly responded to and the following steps will be taken: 1. The Compliance Department shall collect all relevant facts, documents and related information. 2. The report of suspected healthcare related fraud or abuse shall be verified as a valid concern or dismissed. 3. Where an incident involves complex facts, a larger number of individuals or issues requiring application of special investigative expertise, the Compliance Department may consult with and work in conjunction with a contracted entity with specific expertise in the management of fraud and abuse investigations. Page 2 of 6
4. When an incident involves a Molina Healthcare employee, the Compliance Department will involve Human Resources in the investigation and follow up. 5. If the suspected fraud and abuse is verified to be a valid concern, the Compliance Department may consult with Legal Counsel and will report the suspected activity to the appropriate State or Federal regulatory office(s). F. All reports of suspected health-related fraud and abuse will be logged and tracked to include the following information: a. Nature of complaint and any identifying information. b. Date the compliant was made and by whom. c. Outcome of the investigation, including the date. G. In substantiated cases of fraud and/or abuse, Molina Healthcare will work collaboratively with the parties (member, provider, or employee) involved to set forth an appropriate corrective action plan. Depending on the severity of the situation, this could include up to, immediate special member disenrollment, provider contract termination, and employee termination. H. Molina Healthcare will fully cooperate in any investigation by State or Federal regulatory or law enforcement agencies and any subsequent legal action that may result from such investigation. I. Molina Healthcare shall make available to the State of Federal regulatory or law enforcement agencies any and all administrative, financial and medical records relating to the delivery of items or services for which the State or Federal Program funds are expended. Page 3 of 6
Attachment A Federal False Claims Act, 31 USC Section 3279 The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. The act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment. The term knowing is defined to mean that a person with respect to information: Has actual knowledge of falsity of information in the claim; Acts in deliberate ignorance of the truth or falsity of the information in a claim; or Acts in reckless disregard of the truth or falsity of the information in a claim. The act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, doublebilling for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted. Health care fraud is: Health care fraud includes but is not limited to the making of intentional false statements, misrepresentations or deliberate omissions of material facts from, any record, bill, claim or any other form for the purpose of obtaining payment, compensation or reimbursement for health care services. Examples of Fraud and Abuse By a Member Lending an ID card to someone who is not entitled to it. Altering the quantity or number of refills on a prescription Making false statements to receive medical or pharmacy services Using someone else s insurance card Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect By a Provider Billing for services, procedures and/or supplies that have not been actually been rendered Providing services to patients that are not medically necessary Balancing Billing a Medicaid member for Medicaid covered services Double billing or improper coding of medical claims Intentional misrepresentation of manipulating the benefits payable for services, procedures and or supplies, dates on which services and/or Page 4 of 6
information to receive benefits Pretending to be someone else to receive services Falsifying claims treatments were rendered, medical record of service, condition treated or diagnosed, charges or reimbursement, identity of Provider/Practitioner or the recipient of services, unbundling of procedures, noncovered treatments to receive payment, upcoding, and billing for services not provided Concealing patients misuse of Molina Health card Failure to report a patient s forgery/alteration of a prescription Other Provider Crimes Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients. A physician knowingly and willfully referring Medicare or Medicaid patients to health care facilities in which or with which the physician has a financial relationship. (The Stark Law) Balance billing asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider s usual and customary fees. Preventing Fraud and Abuse Healthcare fraud is rising higher and higher every year. Molina and other State and Federal agencies are working together to help prevent fraud. Here are a few helpful tips on how you can help prevent healthcare fraud and abuse: Do not give you Molina ID card or number to anyone except your doctor, clinic, hospital or other healthcare provider. Do not let anyone borrow your Molina ID card. Never lend your social security card to anyone. When you get a prescription make sure the number of the pills in the bottle matches the number on the label. Never change or add information on a prescription. If your Molina ID card is lost or stolen, report it to Molina immediately. Reporting Fraud and Abuse You may report suspected cases of fraud and abuse to Molina s Compliance Officer. You have the right to have your concerns reported anonymously to Molina. Remember to include the following information when reporting suspected fraud or abuse: Page 5 of 6
Nature of complaint The names of individuals and/or entity involved in suspected fraud and/or abuse including address, phone number, Medicaid ID number and any other identifying information. Molina Healthcare of Utah Confidential Compliance Hotline Voice Mail: 866-421-8090 Confidential Email: mhucompliance@molinahealthcare.com Confidential Fax: 866-472-0602 To submit a written report via postal mail: (Marked Confidential) Compliance Officer Molina Healthcare of Utah 7050 Union Park Center, Suite 200 Midvale, UT 84047 You may also report suspected fraud and abuse directly to the State. For suspected Provider fraud or abuse, contact the Utah Department of Health by calling the Medicaid Information Line at 1-800-662-9651, ask for the Utilization Department. For suspected Member fraud or abuse, contact the Utah Department of Workforce Services by calling the Information Fraud Line at 1-800-955-2210. Page 6 of 6