20-401 Fraud, Waste and Abuse Responsibilities
Date: 05/12/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
You can help prevent fraud, waste and abuse by reporting it
Health care fraud contributes to the rising cost of health insurance and reduces the amount of funds available to pay honest providers. Health Net* investigates allegations of fraud, waste and abuse (FWA) and reports of noncompliance at every level.
Definitions
Fraud is intentional misrepresentation or deception for the purpose of obtaining payment or other benefits not otherwise due. Waste is the overutilization or inappropriate utilization of services and misuse of resources. Abuse includes those practices that are inconsistent with accepted sound fiscal, business or medical practices.
Below are examples of fraud, waste and abuse:
- Intentional misrepresentation of services rendered.
- Deliberate application for duplicate reimbursement.
- Intentional improper billing practices.
- Failure to maintain adequate records to substantiate services.
- Failure to provide services that meet professionally recognized standards of health care.
- Conducting excessive office visits or writing excessive prescriptions.
- Provision of unnecessary services.
Delegated PPG responsibility
Delegated participating physician groups (PPGs) are required to have policies and procedures to detect and deter FWA, including a compliance program as defined in Title 42 CFR section 438.608(a). PPGs must comply with all applicable state and federal laws and regulations.
PPGs must report any suspected case of FWA to Health Net within 10 calendar days through the Special Investigations Unit listed on page 2. Additionally, if a PPG receives information about a change in circumstances that may affect a member’s eligibility (e.g., a change in residence or income or the death of a member) they must promptly contact the Health Net Medi-Cal Provider Services Center at 1-800-675-6110.
Health Net Delegation Oversight will monitor and evaluate your compliance to all requirements through:
- Health Net annual Compliance audit
o Review of Compliance program policies and procedures including:
- Compliance program description (requirements defined in Title 42 CFR section 438.608(a))
- Mechanisms for detection and prevention of FWA
- Training program for employees and providers
- Plan for routine internal monitoring
- Disciplinary guidelines for non-compliance
o Proof of process execution (meeting minutes, staff interviews, logs, etc.)
o Evidence of routine monitoring
- Additional activities as identified
For more information on these requirements, refer to the Health Net provider operations manual or contact your assigned Health Net Delegation Oversight compliance auditor.
How to report fraud, waste and abuse
Health Net has adopted processes to receive, record and respond to reports of potential or actual FWA from contractors, agents, directors, enrollees, and first-tier, downstream and related entities (FDRs). Health Net maintains confidentiality to the extent possible, allows callers to remain anonymous if desired and ensures non-retaliation against those who report suspected misconduct in good faith.
To report suspected FWA, contact Health Net Special Investigations Unit at 1-866-685-8664 or mail at:
Health Net, Inc. Special Investigations Unit
1370 Timberlake Manor
Chesterfield, MO 63017
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website at provider.healthnet.com.
Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 1-800-675-6110.