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Healthcare Fraud, Waste & Abuse (FWA)

The federal government has made important strides in reducing fraud, waste and proper payments across the government. The Affordable Care Act provided additional resources and tools to enable the Centers for Medicare & Medicaid Services (CMS) to expand its efforts to prevent fraud, waste and improper payments.i

Health care fraud and abuse is a national problem that affects everyone either directly or indirectly. National estimates show that billions of dollars are lost to health care fraud and abuse on an annual basis. These losses lead to increased health care costs and potential increased costs for coverage.

In an effort to be a part of the solution Village Care is committed to detecting, correcting, and preventing fraud, waste, and abuse and we encourage our contracted physicians, other healthcare providers, and business partners to also take steps to prevent, detect, and immediately correct any instances of FWA.
 

What is Fraud, Waste & Abuse

Fraud – is knowingly and willfully making material false statements or representations of facts that an individual knows to be false or does not believe to be true in order to obtain payment or other benefit to which one would otherwise not be entitled to.

Waste – is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs.ii Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.

Abuse – is the practice that directly or indirectly result in unnecessary costs or improper payments for services which fail to meet recognized professional standards of care. Payments received are the result of an individual or entity knowingly and/or intentionally misrepresenting facts to obtain payment.

The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program. Health care fraud is punishable by imprisonment up to 10 years. It is also subject to criminal fines up to $250,000.
 

Fraud, Waste & Abuse Training and General Compliance Training Requirements

Village Care has adopted training content published by the Centers for Medicare & Medicaid Services (CMS) that addresses this subject matter. For purposes of the relationships that contracted healthcare providers and business entitiesiii have with VillageCareMAX, this training, including all references and requirements related to Medicare Part C and Part D, applies to them as well. This includes our Medicare Part C & D (DSNP), and Medicare-Medicaid (FIDA) plans.

Contracted healthcare providers and business partners supporting Village Care’s Medicare and/or Medicaid products must use CMS content to train their employees and those supporting them to meet certain contractual obligations of Village Care.

Information regarding Compliance and Fraud Waste & Abuse training can be found on our site at the following: https://www.villagecaremax.org/provider-compliance/
 

VillageCareMAX Special Investigation Unit (SIU)

Who is the special investigation unit and what do we do?

The SIU includes a staff of trained professionals who carefully review all allegations of suspected fraud and abuse. This staff includes individuals with the following credentials: Accredited Healthcare Fraud Investigators (AHFI), Certified Fraud Examiners (CFE), Former OMIG, NYPD and MFCU Investigators and Certified Coders and Clinicians.

Special Investigations Unit’s mission is to detect, investigate, prevent and recover the loss of corporate and customer assets resulting from fraudulent and abusive actions committed by providers, members, groups, brokers, and others. We may also recommend the prosecution of individuals /entities that have been found to have committed fraud.

The SIU is dedicated to detecting, investigating, preventing, prosecuting and recovering the loss of corporate and customer assets resulting from fraudulent and abusive actions committed by providers, subscribers, and employees.

Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:

  • Contact with relevant parties to gather information. This may include contacting members to get a better understanding of the situation. For example, we may contact a member to ask about a visit with his or her physician. We may ask the member to describe the services provided and by whom etc.
  • We may request medical, dental, or pharmacy records. This is done to validate that the records support the services billed. It’s important that the provider submits all records requested in a timely manner in order for us to make a fair and appropriate assessment.
  • We may provide notification of suspected fraud and abuse to law enforcement and CMS, if applicable, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare Part C (medical) and Part D (prescriptions), and any other applicable state and/or federal agencies.
  • You have the option for your report to remain anonymous. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, Village Care Legal Department, or other Senior Management).

The SIU investigative process may include, but is not limited to, review and analysis of claims data for member services, correspondence, bills, benefit statements, financial records, utilization management, billing patterns, claims history, query sanctions, disciplinary issues, court records, and insurance activities related to the provider, and interviews with persons with information relating to suspected fraud or abuse
 

Everyday Examples of Health Care Fraud Waste & Abuse:

Examples of actions that may constitute Medicare fraud include:

  • Knowingly billing for services/supplies not provided furnished or supplies not provided, including billing Medicare for appointments the patient failed to keep
  • Billing for nonexistent prescriptions
  • Knowingly altering claim forms, medical records, or receipts to receive a higher payment

 

Examples of actions that may constitute Medicare waste include:

  • Conducting excessive office visits or writing excessive prescriptions
  • Ordering excessive laboratory tests

 

Examples of actions that may constitute Medicare abuse include:

  • Billing for unnecessary medical services
  • Billing for brand name drugs when generics are dispensed
  • Excessively charging for services or supplies
  • Misusing codes on a claim, such as upcoding or unbundling codes

 

To report any instances of Potentially Fraudulent activity you may contact the Hotline available 24/7 call 1-844-348-2664 or log in a ticket at villagecare.ethicspoint.com.

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https://www.cms.gov/outreach-and-education/outreach/partnerships/fraudpreventiontoolkit.html, https://omig.ny.gov/fraud/fraud-abuse

ii As defined in the CMS Medicare Learning Network

iii CMS designates these as first tier, downstream or related entities (FDRs).

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