Fraud, Waste, and Abuse
Provider fraud training
AmeriHealth Caritas VIP Care is committed to detecting and preventing the acts of fraud, waste, and abuse. Take your mandatory provider training (PDF).
Defining fraud, waste, and abuse
AmeriHealth Caritas VIP Care receives state and federal funding for payment of services provided to our members. In accepting claims payment from the plan, health care providers are receiving state and federal program funds and are therefore subject to all applicable federal and/or state laws and regulations relating to this program.
Violations of these laws and regulations may be considered fraud or abuse against the Medicare program. Providers are responsible for knowing and abiding by all applicable state and federal laws and regulations.
Fraud
Fraud is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themselves or some other person. Providers should be aware of applicable federal and state laws, which detail specific acts that constitute fraud.
Waste
Waste is an overutilization of services or other practices that directly or indirectly results in unnecessary costs. Waste is not considered to be caused by criminally negligent actions, but rather is the misuse of resources.
Abuse
Abuse is provider practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary costs to the federally funded programs, reimbursement for services that are not medically necessary, or provider practices that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the federally funded programs.
Examples of fraud, waste, and abuse
Provider fraud, waste, or abuse include but are not limited to:
- Billing for services not furnished
- Submitting false information to obtain authorization to furnish services or items to Medicare recipients
- Accepting kickbacks for patient referrals
- Violating physician self-referral prohibitions
- Billing for a more costly service than the one performed
- Providing, referring, or prescribing services or items that are not medically necessary
- Providing services that do not meet professionally recognized standards
Examples of member fraud, waste, or abuse
Member fraud, waste, or abuse include but are not limited to:
- Fraudulent activities (forged/altered prescriptions or borrowed cards)
- Repetitive emergency room visits with little or no PCP intervention or follow-up
- Same/similar services or procedures in an outpatient setting within one year
- A member using someone else’s insurance card to receive care
- Forging or altering prescriptions/medications, trafficking SNAP benefits, or taking advantage of the system in any way
If upon review by AmeriHealth Caritas VIP Care there is an indication of recipient misuse, abuse, or fraud, the member will be placed on the Recipient Restriction Program, which means the member(s) can be restricted to a single PCP, pharmacy, or hospital/facility for a period of five years.
Restriction to one network provider of a particular type will help ensure coordination of care and facilitate more focused medical management.
Screening employees for federal exclusion
All individuals and entities whose functions are a necessary component of providing items and services to Medicare recipients, and who are involved in generating a claim to bill for services or are paid by Medicare, should be screened for exclusion from the federal healthcare programs before you employ and/or contract with them. If hired, they should be rescreened on an ongoing monthly basis to capture exclusions and reinstatements that have occurred since the last search. Examples of individuals or entities that providers should screen for exclusion include but are not limited to:
- An individual or entity who provides a service for which a claim is submitted to Medicare
- An individual or entity who causes a claim to be generated to Medicare
- An individual or entity whose income derives all or in part from Medicare funds, directly or indirectly
- Independent contractors if they are billing for Medicare services
- Referral sources, such as providers who send a Medicare recipient to another provider for additional services or a second opinion related to a medical condition
Medicare providers who employ or enter into contracts with individuals or entities to provide items or services to Medicare recipients when those individuals or entities are excluded from participation in any Medicare, Medicaid, or other federal health care programs are subject to termination of their enrollment in and exclusion from participation in the Medicare program and all federal health care programs, recoupment of overpayments, and imposition of civil monetary penalties.
View the list of excluded individuals/entities (LEIE) database.
The System for Award Management (SAM) is an official website of the U.S. government. Search for entity registration and exclusion records.
Fraud and abuse laws and regulations
The civil False Claims Act, 31 United States Code (U.S.C.) Sections 3729–3733, protects the federal government from being overcharged or sold substandard goods or services. The civil False Claims Act imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the federal government.
The terms “knowing” and “knowingly” mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No specific intent to defraud is required to violate the civil False Claims Act.
Examples: A physician knowingly submits claims to Medicare for medical services not provided or for a higher level of medical services than the services provided.
Penalties: Civil penalties for violating the civil False Claims Act may include recovery of up to three times the amount of damages sustained by the government because of the false claims, plus financial penalties per false claim filed. Additionally, under the criminal False Claims Act, 18 U.S.C. Section 287, individuals or entities may face criminal penalties for submitting false, fictitious, or fraudulent claims. These penalties may include fines, imprisonment, or both.
The Anti-Kickback Statute, 42 U.S.C. Section 1320a-7b(b), makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration, directly or indirectly, to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a federal health care program. When a provider offers, pays, solicits, or receives unlawful remuneration, the provider violates the Anti-Kickback Statute.
Note: Remuneration includes anything of value, such as cash, free rent, hotel stays and meals, and excessive compensation for medical directorships or consultancies.
Example: A provider receives cash or below-fair-market-value rent for medical office space in exchange for referrals.
Penalties: Criminal penalties and administrative sanctions for violating the Anti-Kickback Statute may include fines, imprisonment, and exclusion from participation in the federal health care program. Under the Civil Monetary Penalties Law (CMPL), penalties for violating the Anti-Kickback Statute may include three times the amount of the kickback. The safe harbor regulations, 42 Code of Federal Regulations (C.F.R.) Section 1001.952, describe various payment and business practices that, although they potentially implicate the Anti-Kickback Statute, are not treated as offenses under the Anti-Kickback Statute if they meet certain requirements specified in the regulations. Individuals and entities remain responsible for complying with all other laws, regulations, and guidance that apply to their businesses.
The Physician Self-Referral Law, 42 U.S.C. Section 1395nn, often called the Stark Law, prohibits a physician from referring patients to receive designated health services payable by Medicare or Medicaid to an entity with which the physician or a member of the physician’s immediate family has a financial relationship, unless an exception applies.
Example: A physician refers a beneficiary for a designated health service to a clinic where the physician has an investment interest.
Penalties: Penalties for physicians who violate the Stark Law may include fines, civil monetary penalties (CMPs) for each service, repayment of claims, and potential exclusion from participation in the federal health care programs.
Source: Office of the Inspector General, https://oig.hhs.gov/
Anonymously report suspected fraud, waste, or abuse
If you, or any entity with which you contract to provide health care services on behalf of AmeriHealth Caritas VIP Care beneficiaries, become concerned about or identify potential fraud, waste, or abuse, please contact:
AmeriHealth Caritas VIP Care
Call: Fraud Tip Hotline at 1-866-833-9718.
Email: fraudtip@amerihealthcaritas.com
Mail: Special Investigations Unit, 200 Stevens Drive, Philadelphia, PA 19113
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Medicare |
State contact information |
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AmeriHealth Caritas VIP Care |
Federal agency name: U.S. Department of Health and Human Services
Online: https://oig.hhs.gov/fraud/report-fraud/ Mail: U.S. Department of Health and Human Services Office of Inspector General ATTN: OIG HOTLINE OPERATIONS P.O. Box 23489 Washington, DC 20026 |
Additional resources
Waste and recovery
Examples of waste include but are not limited to:
- Overpayment due to incorrect set-up or update of contract/fee schedules in the system.
- Overpayments due to claims paid based upon conflicting authorizations or duplicate payments.
- Overpayments resulting from incorrect revenue/procedure codes or retroactive third-party liability/eligibility.
The Payment Integrity Department is responsible for identifying and recovering claim overpayments. The department performs several operational activities to ensure the accuracy of providers’ billing submissions. The department utilizes internal and external resources to prevent the payment of claims associated with waste and to initiate recovery when overpaid claims are identified.
As a result of these claims accuracy efforts, providers may receive letters from AmeriHealth Caritas VIP Care or on behalf of AmeriHealth Caritas VIP Care, regarding recovery of potential overpayments and/or requesting medical records for review.
Please refer to our Provider Manual (PDF) or the letter you received to learn how to return overpayments. You should also use the contact information provided in the letter to expedite a response to questions