Healthcare Fraud Alert
VillageCareMAX cares about your health and safety. We want to make sure you protect yourself from individuals who are trying to steal your personal information in a number of ways such as through phone calls, door-to-door visits and social media.
What You Can Do to Protect Yourself
More and more individuals are being targeted by Medicaid/Medicare scammers – falling for one of these scams can result in compromised healthcare coverage, medical identity theft, financial loss and emotional distress. The best way to protect yourself from common scams is by never sharing your personal information (Social Security Number, credit/bank account numbers, Medicaid/Medicare ID numbers) with someone you don’t know. Additionally, you should always review your health plan claims summary forms for errors.
The most common scams to look out for are:
- Fake renewal requests – where you are told that your coverage is at risk or that you need to pay a fee to renew or reinstate your benefits
- Threats and false promises – where you are threatened with penalties or provided with false offers to lure you into providing your information
- Impersonation of government officials – where scammers pretend to be from government agencies in order to obtain your information
If you receive a call from someone claiming to be from VillageCareMAX and suspect that it is not legitimate – please hang up and call us directly at the number on the back of your insurance card.
Report Complaints
If you believe that someone is trying to steal your information, you can report your complaint to VillageCareMAX. Please call Member Services at 1-800-469-6292 from 8:00 AM to 8:00 PM, 7 days a week. TTY users should call 711. We will work with Medicare to review your concerns and follow up with you on the decision.
The federal government has made important strides in reducing fraud, waste and abuse (FWA) related improper payments across the government. The Affordable Care Act provided additional resources and tools to enable the Centers for Medicare & Medicaid Services (CMS) to expand its efforts to prevent FWA related improper payments.
Healthcare FWA is a national problem that affects everyone. National estimates show that billions of dollars are lost to healthcare FWA on an annual basis. These losses lead to increased healthcare costs and potentially increased costs for coverage.
Our Commitment
VillageCareMAX is committed to detecting, correcting, and preventing FWA and we encourage our contracted physicians, other healthcare providers, business partners, and members to also take steps to prevent, detect, and immediately correct any instances of FWA.
What is Fraud, Waste & Abuse
Fraud – is knowingly and willfully making materially false statements or representations of fact that an individual knows to be false or does not believe to be true in order to obtain payment or other benefits to which they would otherwise not be entitled to.
- Examples of actions that may constitute fraud include:
- Knowingly billing for services/supplies not provided or furnished, including billing for appointments patients failed to keep
- Billing for nonexistent prescriptions
- Knowingly altering claims forms, medical records, or receipts to receive a higher payment
Waste – is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs.
- Examples of actions that may constitute waste include:
- Conducting excessive office visits
- Writing excessive prescriptions
- Ordering excessive laboratory tests
Abuse – is any practice that directly or indirectly results in unnecessary costs or improper payments for services which fail to meet recognized professional standards of care.
- Examples of actions that may constitute abuse include:
- Billing for unnecessary medical services
- o Billing for brand name drugs when generics are dispensed
- o Excessively charging for services or supplies
- o Misusing codes on a claim, such as upcoding or unbundling codes
It is a criminal offense to knowingly and willfully execute a scheme to defraud a healthcare benefit program. A conviction for healthcare fraud may result in incarceration, civil and criminal fines and exclusion from federal healthcare programs.
Fraud, Waste & Abuse Training Requirements
VillageCareMAX provides all employees with mandatory, onboarding and annual FWA training – all materials used for training purposes align with CMS published materials. Additionally, VillageCareMAX contracted healthcare providers and business partners supporting VillageCareMAX’s Medicare and/or Medicaid products are contractually obligated to use CMS content to train their employees and all others supporting them in their delivery of services to VillageCareMAX and our members. The training includes information re: FWA and other requirements related to Medicaid and Medicare Part C and Part D.
Fraud, Waste and Abuse Public Awareness Program:
What is VillageCareMAX Doing to Detect, Prevent and Correct FWA?
VillageCareMAX has engaged a Special Investigations Unit (SIU) vendor to work in conjunction with its Corporate Compliance Team to implement its FWA prevention program. The Corporate Compliance Team and SIU are tasked with reviewing and addressing all allegations of suspected FWA and with ensuring compliance with all other applicable legal and regulatory requirements. The SIU is further tasked with continuous scanning of billed claims to identify patterns or anomalies that could indicate the existence of FWA.
The SIU includes a staff of trained professionals with extensive credentials relevant to the field of healthcare fraud investigations and is dedicated to detecting, investigating, preventing, prosecuting and recovering lost assets resulting from fraudulent, wasteful and abusive actions committed by providers, members, or employees.
Investigation Process
VillageCareMAX’s investigation process will vary, depending on the situation and allegation. Investigational steps may include, but are not limited to the following:
- Contacting relevant parties to gather information. This may include contacting members to get a better understanding of the situation. For example, we may contact a member to ask about a visit with his or her physician. We may ask the member to describe the services provided and by whom, etc.
- We may request medical, dental, or pharmacy records. This is done to ensure that the records support the services billed. It’s important that providers submit all records requested in a timely manner for us to make a fair and appropriate assessment.
- We may provide notification of suspected fraud, waste and abuse to law enforcement and CMS, if required, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare Part C (medical) and Part D (prescriptions), and any other applicable state and/or federal agencies.
- We provide the option for reports to remain anonymous. All information received or discovered by the Corporate Compliance Team and/or the 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, VillageCareMAX’s Legal Department, or other Senior Management).
The SIU’s investigative process may include, but is not limited to, review and analysis of claims data for member services, correspondence, bills, benefit statements, financial records, utilization management, billing patterns, claims history, query sanctions, disciplinary issues, court records, insurance activities related to the provider, and interviews with persons with information relating to suspected fraud, waste or abuse.
Provider Self-Disclosure Requirements
Any person who has received an overpayment, directly or indirectly, must report the overpayment to both VillageCareMAX and the appropriate government agency within sixty (60) days of identification.
- For Medicaid/MLTC overpayments – providers must submit a Self-Disclosure Statement to the OMIG’s Self-Disclosure Program
- For Medicare overpayment – providers must report the overpayment via the Office of the Inspector General (OIG) Self-Disclosure Protocol
Reporting Potentially Fraudulent Activity
To report any instances of potentially fraudulent activity you may contact our anonymous Hotline, which is available 24/7 at 1-844-348-2664 or submit a ticket at villagecare.ethicspoint.com
