Recognizing and Preventing Fraud and Abuse
Magellan is committed to its role in preventing and detecting health care fraud and abuse, and complying with applicable federal and state laws such as the Deficit Reduction Act of 2005. We safeguard against the potential for and promptly investigate reports of suspected fraud and abuse by employees, providers, and others with whom we do business.
What is Fraud?
Fraud is making false statements or misrepresentations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of another party. In order to be considered fraud, the act must be performed knowingly, willfully and intentionally.
What is Abuse?
Abuse describes practices that, either directly or indirectly, result in unnecessary costs, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse is similar to fraud except that one is not required to prove or demonstrate that abusive acts were committed knowingly, willfully and intentionally.
Provider Fraud
Magellan monitors provider practices, including claims data, to assure billing is appropriate and accurate for the services provided and for the funding stream. We investigate allegations of fraud or abuse, and report them to the Department of Human Services and the Department of Public Health.
The most-common types of fraud by providers include the following:
- Billing for services not rendered - Accounts for many health care fraud cases. This can be as simple as billing for a therapy session that did not happen.
- Up-coding/exaggeration of diagnosis or services performed - Deliberately billing for a more expensive service than that which was actually performed; for example, billing for a 50-minute therapy session when only a 20-minute session was performed.
- Unbundling - Billing separately for professional or ancillary services that would ordinarily be included in a facility’s per diem rate is an example of unbundling.
- Misrepresentation of non-covered services - Describing a non-covered procedure in such a way that it would “fit” into a covered service; for example, billing a phone conversation with a patient as a face-to-face service.
Provider Responsibilities
Periodically review your billing practices and implement billing accuracy procedures. Make sure that you and your staff are fully informed about related regulations and that you are operating in full compliance with all applicable federal and state laws.
Be aware of your contractual obligations as a Magellan provider to inform us upon the initiation of any investigation or other action that could lead to loss or restriction on your professional or operating licenses or certifications, “including those of a clinician employed or under contract with a Facility.” You also must notify Magellan of any charges of malpractice, or professional or ethical misconduct, “including any clinician employed by or under contract with a Facility.”
Ensure that you are not employing anyone with 5 percent or more ownership interest in the practice who is on the General Services Administration Debarment list or the Office of Inspector General Exclusion list. These lists can be reviewed through the following websites:
- LEIE (List of Excluded Individuals/Entities) – http://oig.hhs.gov/fraud/exclusions/listofexcluded.html
- EPLS (Excluded Parties List System) – http://www.epls.gov/.
Report suspected fraud or abuse by contacting the Magellan Special Investigations Hotline at 1-800-755-0850.
Additional Information
You can access the Iowa Plan Provider Handbook Supplement (PDF) on this website.
Copies of our False Claims and Whistleblower Protection policy, Medicaid Fraud and Abuse Program policy, State False Claims Laws summary and Compliance Handbook are available upon request by contacting the Compliance Hotline at 1-800-915-2108 or compliance@MagellanHealth.com
For more information on your contractual obligations, please contact Gloria Scholl, area contract manager, at 1-515-273-5048 or GJScholl@MagellanHealth.com.
For more information on Magellan’s Fraud and Abuse program or other compliance issues, contact Chris Sims, director of Quality and Compliance, at 1-515-273-5024 or CSims@MagellanHealth.com.