Magellan Health

Benefits & Services

Fraud, Waste & Abuse

Definitions:

  • Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unneccessary cost to the Nebraska Medicaid Program or in reimbursement for services that are not mediically necessary or that fail to meet professionally recognized standards for health care. Abuse also includes recipient practices that result in unnecessary costs to the Nebraska Medicaid Program.
  • Fraud - Fraud is definded as knowingly and intentionally executing, or attempting to execute a scheme or artifice to defraud any health care benefit program. It is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him, herself or some other person. It includes, but is not limited to the willful false statement or representation, or impersonation or other device, made by a recipient or applicant, provider, departmental employee, or any other person for the purpose of obtaining or attempting to obtain, or aiding and abetting any person to obtain:
      1. Any commodity, food items, food coupons, or payment to which the individual is not entitled
      2. A larger amount of payment than that to which the individual is entitled
      3. Any other benefit administered by the Nebraska Deparment of Social Services to which the individual is not entitled
      4. Assistance in violation of any statutory provision relating to programs administered by the Nebraska Department of Social Services.
  • Waste - Excessive or improper use of services or actions that is inconsistent with acceptable business or medical practice. Medicaid Waste refers to incidents that, although not fraudulant, may directly or indirectly cause financial loss.
  • Overpayments - Any amount that is not authorized to be paid by the Medicaid Program, whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, waste, or mistake.

 

Examples of Fraud , Waste, Abuse, and Overpayment include:

  • Billing twice for health care services that are not needed
  • Billing twice for the same service
  • Using a billing code to get extra payments
  • Using another person's identity to get Medicaid services
  • Making false documents by changing:
      1. The date of service for a claim
      2. Medical records
      3. Referral forms
  • Paying or taking a bribe
  • Billing for services or procedures that have not been performed or have been performed by others
  • Submitting false or misleading information about services performed
  • Misrepresenting the services performed (e.g., up-coding to increase reimbursement)
  • Retaining and failing to refund and report overpayments (e.g., if your claim was overpaid, you are required to report and refund the overpayment, and unpaid overpayments also are grounds for program exclusion)
  • Providing or ordering medically unnecessary services and tests based on financial gain
  • An individual provider billing multiple codes on the same day where the procedure being billed is a component of another code billed on the same day (e.g., a psychiatrist billing individual therapy and pharmacological management on the same day for the same patient)
  • Submitting claims for the services ordered by a provider that has been excluded from participating in federally and/or state-funded helath care programs
  • Lying about credentials, such as degree and licensure information

 

Reporting Medicaid Fraud, Waste, Abuse, & Overpayments

If you think an individual, company, or provider is committing fraud, waste, abuse, or retaining overpayments, please report it. You can report it to Magellan or directly to a State regulatory agency.

Report Fraud, Waste, Abuse, & Overpayments to Magellan
You can report fraud, waste, abuse, and overpayments to Magellan's Special Investigations Unit (SIU)

  • Magellan's Special Investigations Unit hot-line: 1-800-755-0850
  • Magellan's Special Investigations Unit Email: SIU@magellanhealth.com

You can also report fraud, waste, abuse, and overpayments through the Magellan Corporate Compliance hotline which is available 24 hours a day, seven days a week. It is handled by an outside company. Callers do not have to give their names. All calls will be investigated and will remain confidential.

Report Fraud, Waste, Abuse, & Overpayments to State Agencies
You can report suspected cases of fraud, waste, abuse, and overpayments directly to the agencies listed below:

Medicaid fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities can also be reported directly to the Nebraska State Government. Visit the Nebraska Medicaid Reform: Program Integrity website for more instructions.

  1. Attorney General's Office: To report suspected Medicaid Provider Fraud or possible abuse, neglect or financial exploitation of patients in Medicaid facilities, contact the Medicaid Fraud and Patient Abuse Unit of the Attorney General's Office at (402) 471-3549 or toll free at 1-800-727-6432, 1221 N Street, Suite 500, Lincoln, NE 68509-8920, or by email: ago.medicaid.fraud@Nebraska.gov
  2. Nebraska Medicaid Program Integrity - to report Nebraska Medicaid provider self-disclosure, contact Nebraska Medicaid Program Integrity, PO Box 95026, Lincoln, NE 68509 or toll free at 1-877-255-3092 or by email at DHHS.MedicaidProgramIntegrity@Nebraska.gov MLTC-61 "Self-Disclosure Form"
  3. To report suspected Medicaid Client Fraud, contact the Special Investiagtion Unit in the Department of Health and Human Services Division of Public Health:

Phone: for Lincoln and greater Nebraska (402)471-9407
Or in Omaha: (402) 595-3789
Email: Investigations.SIU@dhhs.ne.gov

Writen complaints may be submitted in Lincoln to:

Joyce DeLay
DHHS Division of Public Health Investigations
1033 O Street, Suite 500
Lincoln, NE 68508

Written complaints may be sumitted in Omaha to:
Janet Blackman
DHHS Division of Public Health Investigations
1215 S 42nd Street
Omaha, NE 68105

4.  Nebraska Medicaid Fraud Control Unit
2115 State Capitol
P.O. Box 98920
Lincoln, NE 68509-8920
Phone: (402) 471-3549 Fax: (402) 471-4725
Toll Free: (800) 727-6432
Email: medicaid.fraud@notes.state.ne.us



5. Nebraska Department of Insurance
    Insurance Fraud Prevention Division
P.O. Box 82089
Lincoln, NE 68501
Phone: (402) 471-2201
Fax: (402) 471-8335
Email: DOI.FraudPrevention@nebraska.gov

6. U.S. Department of Health & Human Services Office of Inspector General

Contact the Office of the Inspector General at 1-800-447-8477 or by email to HHSTips@oig.hhs.gov or by mail to the address below:

Office of Inspector General
U.S. Deparment of Health & Human Services
ATTN: OIG HOTLINE OPERATIONS
PO Box 23489
Washington DC, 20026

 

Additional Information About Fraud, Waste, & Overpayments

Additional information about fraud, waste, waste and overpayments is available in bothe the National Provider Handbook, the Provider Handbook Supplement, and the Member Handbook (Manual de Miembros).

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