Fraud & Abuse

 

Addressing Fraud, Waste, and Abuse

As part of our efforts to improve the healthcare system, TakeCare has made a commitment to detecting, correcting, and preventing fraud, waste, and abuse.

Success in this effort is essential to maintaining a healthcare system that is affordable for everyone. TakeCare is undertaking a nationwide campaign to get the word out about how contracted physicians, other health care providers, and business partners can help with fraud, waste, and abuse detection, correction, and prevention.

 

What are Fraud, Waste, and Abuse>

Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)

Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse Payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.

 

Fraud, Waste and Abuse Training and General Compliance Training

TakeCare has adopted training content published by the Centers for Medicare & Medicaid Services (CMS) that addresses this subject matter. For purposes of the relationships that contracted health care providers and business partners* have with TakeCare, this training, including all references and requirements related to Medicare Part C and Part D, is applicable to all TakeCare lines of business. This includes Commercial, Medicare Part C and Part D, dual Medicare-Medicaid, and Medicaid.

Contracted health care providers and business partners supporting TakeCare’s Medicare and/or Medicaid products, must use CMS content to train their employees and the entities supporting them to meet certain contractual obligations to TakeCare.

* CMS designates these as first tier, downstream, or related entities (FDRs).

 

Accessing the CMS Training Material/h4>

English Version

  1. Navigate to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
  2. Scroll to the “Fraud and Abuse-related Resources” section
  3. Click on “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training”
  4. Follow the instructions within the CMS document


Compliance Policy

This policy communicates TakeCare's strong and explicit organizational commitment to conducting business ethically, with integrity and in compliance with applicable laws, regulations and requirements. TakeCare requires its contracted health care providers and business partners to uphold a similar commitment to ethical conduct and assure that they, their employees, and downstream entities who support TakeCare comply with the guiding principles outlined in this policy.


How to Report Fraud, Waste, and Abuse

If you suspect fraud, waste, or abuse in the healthcare system, you must report it to TakeCare and we'll investigate. Your actions may help to improve the healthcare system and reduce costs for our members, customers, and business partners.

To report suspected fraud, waste, or abuse, you can contact TakeCare in one of these ways:

  • Phone: English 1-877-484-2411 (TTY 711)
  • Fax: 1-920-339-3613
  • E-mail: medicareservices@takecareasia.com
  • Mail: TakeCare PO Box 6578 Tamuning, Guam 96931 Attention: Compliance

You may remain anonymous if you prefer. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, TakeCare corporate law department, market medical directors or TakeCare senior management).


Most Common Coding and Billing Issues

Some of the most common coding and billing issues are:

  • Billing for services not rendered
  • Billing for services at a frequency that indicates the provider is an outlier as compared with their peers.
  • Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
  • Billing for services that are actually performed by another provider
  • Up-coding
  • Modifier misuse, for example modifiers 25 and 59
  • Unbundling
  • Billing for more units than rendered
  • Lack of documentation in the records to support the services billed
  • Services performed by an unlicensed provider but billed under a licensed providers name
  • Alteration of records to get services covered

 

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