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Fraud Prevention

Molina Healthcare of Puerto Rico ("Molina") seeks to uphold the highest ethical standards for the provision of health care benefits and services to its members and supports the efforts of federal and state authorities in their enforcement of prohibitions of fraudulent practices by providers or other entities dealing with the provision of health care services.

Definitions:

“Abuse” means practices that are inconsistent with sound fiscal, business or medical practices that result in an unnecessary cost to the Medicaid/Medicare programs or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. (42 CFR 455.2)

"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 (42 CFR 455.2)

"Waste" is health care spending that can be eliminated without reducing the quality of care.

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, double-billing 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, Waste, and Abuse

By a Member By a Provider
Using someone else’s insurance card. False coding, altering records, or claims.
Altering or forging a prescription. False coding, altering records, or claims.
Knowingly enrolling someone not eligible for coverage under their policy or group coverage. Billing separately for services that should be a single service.
Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits. Billing for services not medically necessary.
Altering the billed amount for services. Altering the service date. Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis.
Unbundling of procedures.
Upcoding

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 Healthcare of Puerto Rico’s Compliance Officer. You have the right to have your concerns reported anonymously to Molina, the Patient’s Advocate Office, ASES, and/or United States Office of Inspector General. When reporting an issue, please provide as much information as possible. The more information provided the better the chance the situation will be successfully reviewed and resolved. Remember to include the following information when reporting suspected fraud or abuse:

  • 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.

You may report fraud and abuse to Molina Healthcare through one of the following:

Telephone

The Molina Healthcare AlertLine is available 24/7. It can be reached at any time (day or night), over the weekend, or even on holidays. To report an issue by telephone, call the toll-free at (866) 606-3889.

Online

To report an issue online, visit: https://molinahealthcare.AlertLine.com.

Regular Mail

Write (marked confidential) to: Compliance Officer, Molina Healthcare of Puerto Rico, PO Box 364988, San Juan, PR 00936-4988

You may also contact the Health Advocate Office at 787-977-0909 or, ASES at 1-800-981-2737 or by visiting Molina Healthcare of Puerto Rico, the Patient’s Advocate Office, ASES Offices or Customer Service Centers

For more guidance on this matter you can access the orientation on Fraud, Waste and Abuse section on the ASES website at www.ases.pr.gov. From this section of the website you can download the incident referral document which you can use to report any situation on Fraud, Waste and/or Abuse. Additionally, this section contains the contact information of all the agencies you can call to report any situation on Fraud, Waste and/or Abuse. Upon completing ASES’s incident referral document you have the option of indicating that you do not want to be contacted and/or remain anonymous.​​​​​​

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