Fraud, Waste, and Abuse
Defining fraud, waste, and abuse
Under the HealthChoices program, AmeriHealth Caritas Northeast (the Plan) receives state and federal funding for payment of services provided to our members. In accepting claims payments from the Plan, health care providers are receiving state and federal program funds and are therefore subject to all applicable federal and/or state laws and regulations relating to this program.
As a provider participating in the Plan’s network, you are responsible to know and abide by all applicable state and federal laws and regulations and abide by the fraud, waste, or abuse requirements of the Plan’s contract with the Pennsylvania Department of Human Services (DHS).
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable federal and state law.
The overutilization of services or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions, but rather misuse of resources.
Includes provider reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the health program.
Examples of provider fraud, waste, or abuse
- Billing for services not rendered or not medically necessary.
- Submitting false information to obtain authorization to furnish services or items to Medicaid recipients.
- Prescribing items or referring services that are not medically necessary.
- Misrepresenting the services rendered.
- Submitting a claim for provider services on behalf of an individual who is unlicensed or has been excluded from participation in the Medicare and Medicaid programs.
- Billing an incorrect provider or service location.
- Retaining Medicaid funds that were improperly paid.
- Failing to perform services required under a capitated contractual arrangement.
- Up-coding to a more expensive service than was rendered (such as billing for more time or units of service than provided, or billing a brand name for a generic drug).
Provider screening of employees for exclusion from participation in federal health care programs
As required by the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) and as outlined in DHS Medical Assistance Bulletin 99-11-05, all providers who participate in Medicare, Medicaid, or any other federal health care program are required to screen their employees and contractors, both individuals and entities, to determine if they have been excluded from participation in any of the aforementioned programs.
Employees should be screened for exclusion before employing and/or contracting with them and, if hired, should be rescreened on an ongoing monthly basis to capture exclusions and reinstatements that have occurred since the last search.
The System for Award Management (SAM) is an official website of the U.S. government. Search for entity registration and exclusion records.
Examples of recipient fraud, waste, or abuse
Examples of recipient fraud, waste, or abuse include but are not limited to:
- Member has prescriptions filled at more than two pharmacy locations within one month.
- Member has prescriptions written by more than two physicians per month.
- Member fills prescriptions for more than three controlled substances per month.
- Member obtains refills (especially of controlled substances) before recommended days’ supply is exhausted.
- Duration of narcotic therapy is greater than 30 consecutive days without an appropriate diagnosis.
- Prescribed dose is outside of the recommended therapeutic range.
- Same/similar therapy was prescribed by different prescribers.
- No match between therapeutic agent and specialty of prescriber.
- Fraudulent activities (forged/altered prescriptions or borrowed cards).
- Repetitive emergency room visits with little or no PCP intervention or follow-up.
- Same/similar services or procedures in an outpatient setting within one year.
- Member receives cash assistance (Supplemental Nutrition Assistance Program [SNAP] benefits, heating/energy assistance [LIHEAP], child care, Medical Assistance or other public benefits) and does not report income, ownership of resources or property, or others who live in the household.
- Member allows another person to use his or her ACCESS/MCO card.
- Forging or altering prescriptions/medications, trafficking SNAP benefits, or taking advantage of the system in any way.
Recipient Restriction program
If the results of recipient fraud review indicate misuse, abuse, or fraud, the member will be placed on the Restricted Recipient program, which means the member can be restricted for five years to a single:
Restriction to one network provider of a particular type will ensure coordination of care and provide for medical management. The Recipient Restriction Subcommittee is responsible for identifying, evaluating, monitoring, and tracking potential misutilization, fraud, waste, and abuse by members.
How to report fraud, waste, and abuse to the Plan:
- Call the toll-free Ethics and Compliance Hotline at 1-866-833-9718.
- E-mail: firstname.lastname@example.org
- Mail a written statement to:
AmeriHealth Caritas Pennsylvania/AmeriHealth Caritas Northeast
Special Investigations Unit
200 Stevens Drive
Philadelphia, PA 19113
Reports may be made anonymously.
How to report fraud, waste, and abuse to the Commonwealth:
- Phone: 1-844-DHS-TIPS or 1-844-347-8477
- Online: www.dhs.pa.gov
- Fax: 1-717-772-4655, Attn: MA Provider Compliance Hotline
Bureau of Program Integrity
MA Provider Compliance Hotline
P.O. Box 2675
Harrisburg, PA 17105-2675
How to return improper payments or overpayments:
Contact our Provider Services department immediately at:
- AmeriHealth Caritas Pennsylvania 1-800-521-6007 or
- AmeriHealth Caritas Northeast 1-888-208-7370
There are two ways to return overpayments to the Plan:
- Have the Plan deduct the overpayment/improper payment amount from future claims payments.
- Return the overpayments directly to the Plan by:
- Using the Provider Claim Refund form (PDF).
- Mailing the completed form and refund check for the overpayment/improper payment amount to:
Claims Processing Department
AmeriHealth Caritas Pennsylvania/AmeriHealth Caritas Northeast
P.O. Box 7118
London, KY 40742
Provider self-audit protocol
Providers may also follow the DHS Medical Assistance Provider Self-Audit Protocol to return improper payments or overpayments. Access this voluntary protocol.
Contact Dental Provider Services at 1-855-434-9241.
To return dental overpayments to the Plan, please contact your dental Account Executive.
Provider Fraud Training and Attestation
AmeriHealth Caritas Northeast is committed to detecting and preventing the acts of fraud, waste, and abuse. Take your mandatory provider training here (PDF). Please remember to fill out the attestation after completing the training.Fraud, waste, and abuse provider presentation (PDF) Fraud, waste, and abuse provider training attestation