Fraud Prevention - A Team Effort:
In an effort to prevent fraud and abuse, IEHP encourages providers and their staff to report any suspicious circumstances when they arise. You may want to ask for another form of identification in addition to the IEHP card. Identification with both a picture and a signature, such a valid driver's license or State identification card, are suggested. We are informing Members of this concern and are requesting that they have additional identification available when they come to you.
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Fraud Prevention:
HCFA, now known as the Center for Medicaid and Medicare Services (CMS) and the Office of the Inspector General (OIG) strongly recommend that health plans, hospitals, physician groups and other entities incorporate a compliance program as part of their fraud prevention efforts.
As you know, IEHP has adopted and maintains a Fraud Prevention Program. As part of this program, IEHP expects Providers to also have their own program in place to prevent, detect and resolve suspected fraudulent behavior.
Compliance programs generally follow U.S. Federal Sentencing Guidelines. The OIG has published guidelines for all types of providers. These guidelines are available on-line at http://oig.hhs.gov/fraud.html.
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FAQ:
What are some common schemes of fraud?
PROVIDERS
Billing for services not rendered
Paying a "kickback" in exchange for a referral for medical services or goods
Unbundling
Overcharging for services or goods
Using false credentials
MEMBERS
Allowing unauthorized individuals to use ID Card to obtain benefits
Altering prescriptions
Falsifying residence information to obtain benefits
What do I do if I suspect an IEHP Member is engaging in possible fraud?
First, document your suspicions. Then, contact IEHP directly and explain the case to one of our Representatives. At times, IEHP may request additional information that is necessary to investigate the case. Thus, provider documentation is strongly encouraged. You may also submit a Fraud Report Form along with supporting documents to IEHP. If you have any questions, please contact your IEHP Provider Service Representative.
What do I do if my facility has made some billing errors?
If you suspect that errors in billing may have occurred, contact your IEHP Provider Services Representative at (909) 890-2054.
What are some other things I can do as a Provider?
Periodically perform internal audits of billing practices and compare billing records with payments received.
Do not leave prescription pads, which include a provider's identification and license number, out in the open. For example, do not store prescription pads in examining room cabinets of leave on office counters.
Contacting the OIG
The OIG is there to assist you and maintains a hotline, which offers a confidential means for reporting vital information.
For information on confidentiality, please contact the hotline and ask about our confidentiality source program.
Each caller is encouraged to assist the OIG by providing information on how they can be contacted for additional information but CALLER MAY REMAIN ANONYMOUS.
HOTLINES:
By Phone: 1-800-HHS-TIPS (1-800-447-8477)
By E-Mail: Htips@oc.dhhs.gov
Additional Hotlines
DHS MEDI-CAL FRAUD HOTLINE:
By Phone: 1-800-822-6222
The recorded message may be heard in English and four other languages: Spanish, Vietnamese, Cambodian, and Russian. The call is free and the caller may remain anonymous.
By E-Mail: stopmedicalfraud@dhs.ca.gov
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