13 COMPLIANCE AND ETHICS
13.2 Importance of Detecting, Deterring and Preventing Fraud, Waste and Abuse
Health care fraud costs taxpayers increasingly more money every year. State and federal laws are designed to crack down on these crimes and impose strict penalties. Fraud, waste and abuse in the health care industry may be perpetuated by every party involved in the health care process. There are several stages to inhibiting fraudulent acts, including detection, prevention, investigation and reporting.
Many types of fraud, waste and abuse have been identified, including the following:
Provider fraud, waste and abuse
Providers can prevent fraud, waste and abuse by ensuring the services rendered are medically necessary, accurately documented in the medical records and billed according to American Medical Association guidelines.
Member fraud, waste and abuse
To help prevent fraud, waste and abuse, providers can educate members about these types of fraud and the penalties levied. Also, spending time with patients and reviewing their records for prescription administration will help minimize drug fraud and abuse. One of the most important steps to help prevent member fraud is as simple as reviewing the Medicare member ID card. It is the first line of defense against fraud. IntegraNet may not accept responsibility for the costs incurred by providers rendering services to a patient who is not the plan member, even if that patient presents a Medicare member ID card. Providers should take measures to ensure the cardholder is the person named on the card.
Additionally, encourage members to protect their cards as they would a credit card or cash, carry their IntegraNet member ID card at all times, and report any lost or stolen cards to the health plan as soon as possible.
IntegraNet believes awareness and action are vital to keeping the state and federal programs safe and effective. Understanding the various opportunities for fraud, waste and abuse and working with members to protect their IntegraNet ID card can help prevent fraud, waste and abuse. IntegraNet encourages its members and providers to report any suspected instance of fraud, waste and abuse using the contact methods referenced earlier. No individual who reports violations or suspected fraud, waste or abuse will be retaliated against, and IntegraNet will make every effort to maintain anonymity and confidentiality.