Fraud & Abuse

Health care scams are on a rise, especially during open enrollment season. In many cases, scammers target your personal information to commit medical identity theft. Medical identity theft is when someone steals or uses your personal information to submit fraudulent claims to your health insurer without your authorization.

There are many ways to avoid potential health care fraud and abuse schemes.  Here are some tips to protect yourself against scams:

• • Never share your personal information, including Social Security Number and credit or bank card numbers, by email, text message, or over the phone with someone that you don’t know.
  • Do not respond to calls or texts from unknown numbers or numbers that appear to be suspicious.
  • Never give out your MetroPlusHealth Member ID number or Medicare ID number to people offering you free or discounted medical care, supplies, medications, or equipment.
  • Do not engage with door-to-door solicitors.
  • Hang up on robocalls- these are the calls that prompt you to press any key to be connected to an agent.

If you receive a call from someone who claims to be from MetroPlusHealth and have suspicions that it is not legitimate, please hang up! We encourage our members to call us directly at the number on the back of their insurance card.

To learn more about how to avoid robocalls and caller ID spoofing scams, visit https://www.fcc.gov/consumers/guides/stop-unwanted-robocalls-and-texts, which provides a list of call-blocking and labeling resources.

FRAUD & ABUSE

Report Fraud, Waste or Abuse

MetroPlusHealth is dedicated to helping prevent health care fraud and investigates all allegations of fraud, waste or abuse.

What is fraud?

Fraud is the intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the member, provider, employee, contractor, subcontractor, or another person.

Examples of fraud include:

• • Billing for services that were not rendered
  • Billing for office visits that you did not go to
  • Submitting multiple bills for the same date of service
  • Offering money or goods to use a member identification card
  • Sharing of member identification cards
  • Providing false information in order to obtain insurance coverage

What is abuse?

Abuse means practices that are inconsistent with sound fiscal, business, medical or professional practices, and result in unnecessary costs to a medical assistant program, payments for services that were not medically necessary, or payments for services which fail to meet recognized standards for health care. This also includes member practices that result in unnecessary costs to medical assistance programs.

What is MetroPlusHealth Doing to Stop Health Care Fraud, Waste and Abuse?

MetroPlusHealth has established a Special Investigations Unit (SIU) to investigate cases of potentially fraudulent and abusive activity by all contracted providers. The SIU is staffed with trained professionals with extensive experience and credentials relevant to the field of health care fraud investigations. This Unit works closely with other departments at MetroPlusHealth as well as Federal, State, and local law enforcement agencies and regulatory bodies. The SIU is responsible for coordinating claims data mining to identify fraudulent, wasteful and abusive billing patterns.

The Corporate Compliance department works closely with the SIU to implement the Fraud, Waste, and Abuse Prevention Program across MetroPlusHealth and to ensure compliance with fraud and recovery regulatory reporting requirements. The requirements of the Prevention Plan are incorporated into MetroPlusHealth’s Corproate Compliance Program. As part of its annual training, MetroPlusHealth informs all workforce members and appropriate delegated entities of its FWA Prevention Plan and related activities.

How to report Health Care Fraud, Waste and Abuse?

Help us maintain our commitment to ethical practice by reporting fraud, waste, and abuse when you see it. We encourage employees, members, providers, and vendors to report suspected cases of fraud, waste, abuse, or other violations of company policy in whatever manner they feel most comfortable.

MetroPlusHealth will not retaliate against anyone who in good faith reports suspected fraud, waste and abuse.

You may report such concerns to MetroPlusHealth confidentially in the following ways:

• • Compliance Hotline – completely anonymous and accessible 24 hours a day, 7 days a week, 365 days a year
    • Call 1-888-245-7247, or
    • Submit an online report.

• • Write:

MetroPlus Health Plan
Office of Corporate Compliance
50 Water Street, 7th Floor
New York, NY 10004

• • E-Mail: [email protected]
  • Customer Service: MetroPlusHealth Plan members can always call us 24/7 at 1-800-303-9626 with questions or concerns.

You may also report suspected health care fraud directly to state and federal agencies.

To report fraud to New York State, you may contact:

• • The New York State Office of the Medicaid Inspector General (OMIG) by calling their fraud hotline at 1-877-873-7283 or online at https://omig.ny.gov/medicaid-fraud/file-allegation.

To report Medicare fraud, you may contact:

• • The Office of Inspector General at 1-800-HHS TIPS (1-800-447-8477), or
  • The Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227)

OVERPAYMENTS (for Providers)

MetroPlusHealth has written policies to report, return and explain all overpayments for all federally funded programs. Any person who has received an overpayment, directly or indirectly, has an obligation to report the overpayment to the MetroPlusHealth Compliance Department after they have reported it to the appropriate government agency within sixty (60) days of identification.

In accordance with 18 NYCRR Part 521-3.4(c), Providers must explain overpayments arising from the Medical Assistance Program, such as Medicaid, MLTC, and CHP, by submitting a Self-Disclosure Statement to OMIG’s Self-Disclosure Program. The Statement must be signed by the Provider’s Compliance Officer, or if no Compliance Officer is required, the CEO, COO, a senior manager, or the solo practitioner. Once OMIG accepts the submission of the self-disclosure statement and determines the amount of the overpayment, if any, they will notify the person and the overpayment must be returned with interest, if applicable, to OMIG.

Overpayments arising from Medicare must be reported to CMS in accordance with the either the Self-Referral Disclosure Protocol managed by CMS or the Self-Disclosure Protocol managed by the Office of the Inspector General (OIG).

Providers must notify the MetroPlusHealth Compliance Department of an overpayment in writing by either mail or email:

• • Write:

MetroPlus Health Plan
Attn: Chief Compliance and Regulatory Officer
50 Water Street, 7th Floor
New York, NY 10004

• • E-Mail: [email protected]