Neighborhood Health Providers' Fraud and Abuse Policy
Healthcare fraud and abuse affects everyone. Many types of fraudulent and abusive acts result in billions of dollars spent in lost healthcare dollars and higher taxes to support state and federal healthcare programs. The Federal Government addressed the severity of this in Section 6032 of the Deficit Reduction Act of 2005. This act requires all entities that receive significant funding from the Federal Government to educate employees, contractors and agents about false claims. The vast majority of people are honest; however, there are a few individuals who, through fraudulent or abusive acts, illegally collect money and services.
NHP is committed to identifying, investigating and preventing fraud and abuse. This policy requires all employees, members, providers and other subcontractors to comply with all applicable statutes, regulations and program requirements. This includes program requirements for Medicare Advantage, Medicare Part D, Medicaid, Family Health Plus and Child Health Plus . It also includes state and federal fraud and abuse laws and regulations. NHP is dedicated to supporting and protecting the integrity of state and federal government sponsored programs and requires your cooperation. Neighborhood Health Providers (NHP) has added information about this policy to its Human Resources (Employee) Manual.
What is Healthcare Fraud and Abuse?
Fraud is any type of intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain. The act does not have to be successful; it is enough that the person attempted the deception.
Abuse relates to practices that are inconsistent with sound business, fiscal or medical practices and result in unnecessary costs to the state, federal government or NHP. An example is reimbursement of services that are not medically necessary or do not meet professionally recognized standards for health care.
Common Types of Fraud
Fraud and abuse can take many forms and can be committed by dishonest physicians, medical equipment suppliers, dentists, laboratories, hospitals and other vendors and health care workers or by NHP members. Some of the common types of fraud committed by providers and members are given below.
Members
Member fraud can take many forms. NHP needs the assistance of its members and providers to identify this type of activity. Examples of member fraud include:
- Loaning an insurance identification card, such as your NHP Medicaid or Medicare Advantage card, to another person or using the card of another person;
- Forging or altering a prescription;
- Using more than one insurance identification card;
- Intentionally receiving duplicative, excessive or conflicting health care services or supplies;
- Re-selling items such as prescriptions or medical supplies received through NHP's programs;
- Providing false information when applying to NHP in order to try to obtain coverage;
- Using the transportation benefit for non- medical related business
Providers
Provider fraud can take many forms. NHP needs the assistance of its members and providers to identify this type of activity. Examples of provider fraud include:
- Billing for services, procedures and/or supplies that were not provided, e.g. an x-ray that was not taken;
- Double billing, e.g. when a provider bills NHP and also bills Medicaid fee-for-service
- Requiring a NHP member to return for unneeded services;
- Performing unnecessary procedures (over-utilization), tests or even surgeries;
- Up coding, e.g. providing a simple office visit and billing for a comprehensive visit or performing a simple procedure and billing for a complex procedure;
- Unbundling, e.g. billing for portions of a procedure separately rather than for the whole procedure;
- Having an unlicensed person perform services that only the licensed professional should be performing and then billing as if the licensed professional did perform the service;
- Billing for more service time than actually provided, e.g. counseling or anesthesia;
- Billing for an office visit when there was none, or adding additional family members' names to bills;
- Accepting payment from another provider as payment for referring a patient to that other provider (kickbacks);
- Altering medical records;
- Routinely waiving member co-pays;
- Billing for "phantom" patients who do not exist and did not receive services;
- Billing for more hours than there are in a day.
You Can Help!
Members can assist NHP with identifying provider fraud by keeping track of the following type of information:
- When you used a healthcare professional service
- Where the service took place
- The name of the healthcare professional who provided your care
- What services were provided during the visit and the additional services the provider ordered
If you receive a copy of your explanation of benefits, review it to make sure the services, the name of the provider and the dates of service are correct. If you suspect a provider is billing for more or different services than you actually received, please notify NHP as soon as possible.
You can also remember the following:
- DO NOT give your NHP ID card or card number to anyone other than your doctor, clinic, hospital or other healthcare provider;
- DO NOT ask your doctor or any other healthcare provider for medical services or supplies that you do not need;
- DO NOT sign your name to a blank form;
- DO NOT share your medical records with anyone other than your doctor, clinic, hospital or other healthcare provider
Providers can assist NHP with identifying member fraud by notifying NHP if you suspect an NHP member of being involved in a fraudulent activity. To help prevent fraud, providers can:
- Ask the member for identification if you are unsure if the individual presenting an NHP ID card is the individual named on the card;
- Notify NHP if you believe an individual has tried to use more than one identification card or a card belonging to another individual;
- Notify NHP if you are concerned because the individual appears to be trying to obtain unnecessary services or supplies.
How to Report Suspected Fraud or Abuse
If you suspect fraud or abuse by a member, provider, vendor, employee or other person or entity working with or for NHP , please notify NHP immediately. You may report your concerns to NHP by calling the number on your identification card, your provider services representative, or by calling NHP's Compliance Hotline.
Call the Compliance Hotline to report potential violations of NHP's compliance policies or of state or federal health care program requirements. The toll-free number is listed below:
Compliance Hotline
1-877-655-9900 (toll-free)
Hearing Impaired – use NY Relay Service 1-800-877-8973
The Compliance Hotline is available 24 hours a day, 7 days a week. Calls can be made anonymously if desired and there is NO RETALIATION against an individual reporting a compliance issue or concern regarding improper or unethical activity, such as inaccurate billing or employee conduct.
Remember - if you see something, say something! NHP needs your help to prevent fraud and abuse!
