While most claims
payment errors are just the result of mere oversights, there
continues to be a small number of health care providers who
intentionally engage in conduct intended to defraud the Maryland
Medical Assistance Program. Health care fraud affects everyone,
especially the recipients of care. For that reason, Priority
Partners Managed Care Organization (PPMCO) and the Maryland
Department of Health and Mental Hygiene (DHMH) have joined forces in
a commitment to prevent and detect health care fraud.
Health care fraud is
defined as any deliberate and dishonest act committed with the
knowledge that it could result in an unauthorized benefit to the
person committing the act or someone else who is similarly not
entitled to the benefit. Examples of health care fraud are:
- Billing for items and services that have
not been rendered;
- Billing for services that have not been
properly documented;
- Billing for items and services that are
not medically necessary;
- Misrepresentation of the type or level of
service provided;
- Misrepresentation of the individual
rendering service;
-
Seeking
payment or reimbursement for services rendered for procedures
that are integral to other procedures performed on the same date
of service (unbundling);
- Seeking increased payment or reimbursement
for services that are correctly billed at a lower rate (upcoding);
- Failing to render care that the
practitioner is contractually obligated to provide to Medicaid
recipients;
- Providing substandard care;
- Soliciting or receiving kickbacks in
return for referring patients (with a few exceptions); or
- Any action or inaction that is performed
or withheld in violation of the provider’s contract with PPMCO
or the Maryland Medical Assistance Program
In an effort to deter these
and other instances of fraud, PPMCO’s Corporate Compliance
Department routinely performs validation audits on statistical
samples of claims. In addition, as a result of the recent expansion
of the Compliance Department, plans are underway to broaden those
audits to include encounter and utilization data assessments.
PPMCO’s Corporate Compliance Department investigates all detected
outliers and other deviations from standard practices, and reports
all irregularities not later determined to be mere errors to DHMH
and/or the Maryland Attorney General’s Office Medicaid Fraud Control
Unit (“MFCU”).
PPMCO’s Corporate Compliance Department also investigates
allegations of health care fraud it receives from Medicaid
recipients and others and reports substantiated allegations to the
MFCU. The MFCU may, in turn, perform its own fraud investigation and
take action against those who are found to have committed fraud.
If you have questions about health care fraud
or would like to report fraud committed against PPMCO, please
contact the Corporate Compliance Program directly at 410-424-4996 or
via email at
compliance@jhhc.com.
You may also contact the DHMH Program Integrity Unit at
1-866-654-4421, or via email at:
http://www.dhmh.state.md.us/mma/programintegrity/html/reportfraud.htm
You can remain
anonymous, and all reports are kept confidential.
