Compliance - Fraud, Waste and Abuse

Detecting and preventing fraud, waste, and abuse (FWA) is the responsibility of everyone. The Plan encourages providers, members, affiliates, facilities, vendors, consultants, and contractors to report any suspected fraud, waste or abuse to the Plan’s Compliance Officer directly by calling, emailing or calling anonymously through the hotline.

The Plan will protect its corporate assets and the interests of its members, employers, and providers against those who knowingly and willingly commit fraud or other wrongful acts. We will identify, resolve, recover funds, report, and when appropriate, take legal action if suspected fraud, waste, and/or abuse have occurred.

A provider’s submission of a claim for payment constitutes the provider’s representation that the claim is free of fraud, waste, and abuse, and is submitted in compliance with all federal and state laws and regulations. The definitions of fraud, waste, and abuse and examples are listed below.

Fraud is defined as knowingly and willingly 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.

Health care fraud examples include but are not limited to the following:

• Misrepresentation of the type or level of service provided
• Misrepresentation of the individual rendering a service

Waste is defined as practices which directly or indirectly result in unnecessary costs such as overusing services. It is the misuse of resources.

Examples of healthcare waste include:

• Auto-filling prescriptions that a patient does not need or use
• Ordering excessive lab tests

Abuse is defined as the practice of directly or indirectly billing in such a way that results in unnecessary costs and includes any practice inconsistent with providing patients with medically necessary services meeting professionally recognized standards.

Examples of abuse include:

• Charging for unnecessary medical services
• Charging excessively for services or supplies
• Misusing codes on a claim, such as upcoding or unbundling codes

The provider is responsible for providing guidance to employees, independent contractors, and subcontractors regarding how to report potential compliance issues. The provider is responsible for promptly addressing and correcting all issues brought to your attention.

Providers are responsible for, and these provisions likewise apply to, the actions of their staff members and agents.

Sanford Health Plan routinely verifies charges billed are in accordance with the guidelines stated in this payment policy and are appropriately documented in the member’s medical record. All payments are subject to prepayment audits post-payment audits, and retraction of over-payments. Any amount billed by a provider in violation of this policy and paid by Sanford Health Plan constitutes an overpayment and is subject to recovery. A provider may not bill members for any amounts due resulting from a violation of this policy.

13.1 Prevention Techniques

Fraud, waste, and abuse can expose a provider, contractor, or subcontractor to criminal and civil liability. Waste is and abuse are generally not considered to be caused by negligent actions, but rather the misuse of resources.

The provider is responsible for implementing methods to prevent fraud, waste, and abuse. Listed below are some common prevention techniques. This list is not meant to be all-inclusive.

• Education related to fraud, waste and abuse
• Validation of all member ID cards prior to rendering services (cross-checking with another form of government issued photo ID is a good practice.)
• Ensuring accuracy when submitting bills or claims for services rendered
• Submitting appropriate referral and treatment forms
• Avoiding unnecessary drug prescriptions and/or medical treatments
• Reporting lost or stolen prescription pads and/or fraudulent prescriptions
• Screening all employees and contractors at time of hire/contract and monthly thereafter to prevent reimbursement of excluded and/or debarred individuals and/or entities. Two of the review resources are:
  • SAM– The Excluded Parties List System (“EPLS”) is maintained by the GSA, now a part of the System for Awards Management (“SAM”). The EPLS is an electronic, web-based system that identifies those parties excluded from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non-financial assistance and benefits. The EPLS keeps its user community aware of administrative and statutory exclusions across the entire government, and individuals barred from entering the United States. sam.gov

• LEIE – List of Excluded Individuals and Entities list is maintained by HHS OIG and provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, Marketplace and all Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE exclusions.oig.hhs.gov.

13.2 How to Report

The Plan requires everyone to exercise due diligence in the prevention, detection, and correction of fraud, waste and abuse (FWA). The Plan promotes an ethical culture of compliance with all State and Federal regulatory requirements and mandates the reporting of any suspected or actual FWA to the Plan’s Compliance team. The compliance team can be reached by emailing siuvm-mfld@Sanfordhealth.org or calling the anonymous Compliance Hotline: (877) 473-0911.

13.3 Special Investigations Unit (SIU)

The Plan is committed to program integrity efforts by early identification, correction and prevention of health care FWA through its Special Investigations Unit (SIU). The SIU utilizes various methods in its efforts to address FWA including, but not limited to, investigation and data analytics tools. These resources assist in detecting unusual claim patterns, outlier behavior, over-utilization and potentially inappropriate billing practices.

Procedures are in place to promptly address noncompliance and potential FWA issues, as well as reporting identified issues to appropriate authorities. Actions taken by the SIU may include things such as interviews, medical record reviews, verbal/written provider education, written and documented corrective action plans, recoupment of funds, appropriate federal and state law enforcement/ MEDIC referrals or other legal action.

The provider shall give the SIU the right to audit, evaluate and inspect books, contracts, documents, papers, medical records, patient care documentation and any other pertinent records. A provider audit may result in recoupment, suspension, or termination. The provider shall be notified of the determination by letter. The date on the letter will be deemed as the date of the determination.

If a provider disagrees with the audit results, they may dispute it by responding to the Special Investigations Unit as outlined in the determination letter. Disputes must be submitted to the Plan within 30 days of the initial determination.

Providers are entitled to one dispute per audit granted; there are no extenuating circumstances. For questions or inquiries related to the Special Investigations Unit, please contact siuvm-mfld@Sanfordhealth.org.