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Report Fraud, Waste and Abuse

What Is Fraud, Waste & Abuse?

Healthcare fraud, waste and abuse affects each and every one of us. It costs taxpayers millions of dollars every year and is estimated to account for between 3% and 10% of the annual expenditures for health care in the U.S. 

Here's some more information about each and how you can report it:

Fraud

Health Care fraud is both a state and federal offense. Based on the HIPAA regulations of 1996, a dishonest provider or member may be subject to fines or imprisonment of not more than 10 years, or both (18 USC, Ch. 63, Sec. 1347).

The following is the official definition of Fraud: 

42 CFR §455.2 Definitions.
"Fraud" means an 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.

Here are some examples of fraud:

  • Using a member ID card that belongs to someone else.
  • Altering a prescription written by a doctor.
  • Making false statements to get medical or pharmacy services.
  • Billing for services that were not provided.
  • Billing for the same service more than once.

Waste

The following is the official definition of Waste: 

42 CFR §455.2 Definitions.
"Waste" Involves the taxpayers not receiving reasonable value for money in connection with any government funded activities due to an inappropriate act or omission by player with control over or access to government resources (e.g., executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight. 

Abuse

The following is the official definition of Abuse: 

"Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

Here are some examples of abuse:

  • Using the Emergency Room for non-emergency health care.
  • Going to more than one doctor to get the same prescription.
  • Threatening or offensive behavior at a provider's office, hospital or pharmacy.

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False Claims Act

The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the Government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government's damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud. 

The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit on behalf of the Government against the person or business that committed the fraud. The lawsuit is known as a "qui tam" case, but it is more commonly referred to as a "whistleblower" case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer. 

For more information on the False Claims Act, please contact the Meridian Corporate Compliance Officer at 844-667-3560 (TTY 711).

Jimmo v. Sebelius Information

On January 24, 2013, the U.S District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius. The settlement clarifies skilled care delivery for skilled nursing facilities (SNFs), home health (HH), inpatient rehabilitation (IRFs), and outpatient therapy (OPT) benefits. The Centers for Medicare and Medicaid Services (CMS) has instructed Medicare insurers like Meridian Health Plan to convey this information to our providers to ensure that services are provided and coverage determinations are adjudicated accurately and appropriately in accordance with associated policy.

For documentation requirements, revisions to relevant portions of the Medicare Benefit Policy Manual, frequently asked questions and their responses, please visit the CMS website or review the following materials below: