Fraud is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself, herself or some other person. It includes any act that constitutes fraud under applicable federal or state law.
Waste involves the taxpayers not receiving reasonable value for money in connection with any government funded activities due to inappropriate act or omission by player with control over, or access to, government resources.
Abuse is any provider practices that are inconsistent with sound fiscal, business, or medical practices, and result either in an unnecessary cost to the federally-funded programs or in reimbursement for services that are not medically necessary or provider practices that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the federally funded programs.
Fraud, waste, and abuse hurts everyone.
It can even raise the cost of getting health care services. This is why we need help from our members and providers to find fraud, waste, and abuse and stop it as soon as possible. As our member, you play an important role in helping us find fraud, waste, and abuse. If you feel that it might be happening, report it as soon as you can. Here are some examples of possible fraud:
General Information - Provides monetary penalties that can be imposed upon a health care provider for knowingly and willfully making false statements or representations in connection with filing a claim seeking reimbursement from a federally funded health care program. In this act, the definition of “knowingly” includes actual knowledge, deliberate ignorance and reckless disregard for the truth. Some examples of health care fraud have included: certifications and information, lack of medical necessity, duplicate claims for the same service, submitting claims for an excluded provider, inserting diagnosis codes not obtained from a physician or other authorized individual, etc. There is often some falsification of records to support improper billings.
While Highmark Health Options Duals believes it has confidential reporting and investigative processes in place, employees may consider pursuing under the anti-retaliatory provisions or the False Claims Act contained in 31 U.S.C Sec 3730 (h). These provisions protect workers from retaliation or other illegal treatment and provide ways to recover a share of monetary damages if such damages are awarded to the Federal Government if/when a lawsuit is settled.
General Information - Provides civil and criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive “remuneration” to induce the referral of business. Examples of “remuneration” include services (such as free testing or supplies) as well as items (such as cash, equipment, software, gifts, and other things of value). No bribes, kickbacks or other inappropriate payments should be offered or given to any person or entity for any reason including, but not limited to, the acquisition or retention of business.
General Information - Provides criminal penalties for individuals or entities that do not adhere to the regulations regarding financial arrangements between referring physicians (or a member of the physician’s immediate family) and entities that provided designated health services payable by Medicare or Medicaid. In contrast to the anti-kickback statute, it does not require any showing of the “wrongdoer’s” intent. Penalties can be applied if an arrangement exists that does not satisfy allowed exceptions.
Federal and state laws want providers to regularly audit their claims for overpayment.
Reporting overpayment by form
If an overpaid claim is found, a provider must:
Tell us in writing the reason for the overpayment.
Return the overpayment’s full amount within 60 days of finding it.
Send in the Provider Self-Audit form.
Please complete all information and note:
For claims less than two years old, retracting these claims is preferred.
For claims more than two years old, please provide a check.
If a listing of claims isn’t provided, Highmark Health Options Duals can’t guarantee that the claims won’t be audited again for the same reason.
Depositing a provider check or retracting a requested claims doesn’t mean complete agreement to the submitted self-audit results or overpayment amount.
The Financial Investigations and Provider Review (FIPR) Department may contact the provider to discuss self-audit results as needed.
Reporting overpayment online
Providers can also submit overpayments online using TRENDSubmit. This safe, online process allows providers to get claim retraction updates in real-time.
TRENDSubmit training resources and support is available. Please use these helpful details or send Jennifer Baron an email to get set up.
Helpful Resources
Here are some more ways for Providers to get self-audit information.
We have a team of people who look into all calls or mail regarding possible fraud, waste, and abuse of health care services. You do not have to share your name when making a report. Tell us of suspected fraud, waste, and abuse of services paid for by Highmark Health Options Duals.
Report Medicaid fraud, waste, and abuse by contacting Highmark Health Options Duals through mail, email, or phone. You can also use the secure online form below.
To report Fraud, Waste and Abuse by mail, please send your report to:
Highmark Health Options Duals
HHOFRAUD
120 Fifth Avenue
Pittsburgh, PA 15222
To report Fraud, Waste and Abuse by phone, call 1-844-325-6256.
To report Fraud, Waste and Abuse electronically, send us an email message SIU_HHO@highmark.com.
Use the secure form to share information about the suspected member or provider. This form is to tell us of suspected fraud, waste, and abuse of services paid for by Highmark Health Options Duals. Fill in as much of the information as you can, then click the submit button.
When you get health care services, record the dates on a calendar and save the receipts and statements you get from your doctor to check for mistakes. You should keep track of these things:
Keeping track of your health services will not only help you to improve your health, but it will also help you to know when there is a problem such as fraud. Ways to protect yourself from fraud, waste, and abuse:
Centers for Medicare and Medicaid Services (CMS)
FWA Auditing and Monitoring Plan - Supplemental Reference
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If you need information on covered services:
Check your Medicare D-SNP benefits documents or Medicaid Member Handbook
Call Duals Member Services: 1-855-401-8251 (TTY 711), Monday–Friday, 8 a.m.–5 p.m.
Call Duals Select Member Services: 1-844-722-5837 (TTY 711), Monday-Friday, 8 a.m. – 5 p.m.
To find an in-network provider, search your Provider Directory.
