An Eye on Fraud, Waste and Abuse
A little fraud goes a long way. According to the National Health Care Anti-Fraud Association,$68 billion is lost to health care fraud in the United States each year…raising the cost of care for individuals and families across the country. While not all fraud is discovered, thousands of providers are prosecuted annually for illegal fraud. The federal government has revitalized its commitment to address and eliminate fraud, waste and abuse in our health care system. So we can expect prevention efforts and prosecutions to rise, and for this topic to continue to be headline news.
As a manager of the benefits of millions of members, Magellan takes fraud, waste and abuse seriously. Providers offering services to our members are expected to strictly abide by all federal and state laws and contract requirements designed to prevent fraud, waste and abuse in government programs (such as Medicare and Medicaid) and private insurance.
Health care fraud is an intentional deception or misrepresentation made by an individual, knowing that the misrepresentation could result in some unauthorized benefit to them or to others. The most common kind of health care fraud involves false statements or deliberate omission of information that is critical in the determination of authorization and payment for services. While fraud gets a lot of attention, Magellan is also greatly concerned with waste and abuse in the health care arena. Providers should exercise their best independent judgment when deciding which services to order for their patients and consider, prior to seeking authorizations, whether the services are medically necessary for the member and in the member’s best interest.
To learn more about fraud, waste and abuse, please go to the FAQs section, which has definitions, examples and ways to prevent fraud.
Magellan has engaged in considerable efforts and dedicates substantial resources to prevent fraud, waste and abuse and to identify those committing violations. We actively pursue all suspected cases of fraud, waste and abuse and will work with government agencies and law enforcement for prosecution under the law.
Magellan promotes provider practices that are compliant with all federal and state laws on fraud, waste and abuse. If you have any questions about fraud, waste or abuse, we are happy to work with you for a better understanding. Also, if you think you have detected an instance of either health care fraud or medical identity theft, please contact our Special Investigations Unit (SIU). The SIU can be reached through a 24-hour Fraud Hotline at 1-800-755-0850 or e-mail sent to SIU@MagellanHealth.com.