Fraud and Abuse
Health Plus is committed to protecting the integrity of the government-sponsored programs it offers and the efficiency of its operations by detecting, investigating and preventing fraud and abuse. Health Plus does not tolerate acts that adversely affect the health plan and its ability to care for its members.

In accordance with New York State and Federal Law, Health Plus has established an integrated anti-fraud program, consolidating all related functions under the Corporate Compliance Department and establishing the Special Investigations Unit (SIU). The Corporate Compliance Department SIU is responsible for detecting, investigating and reporting potential fraud and abuse activities. Health Plus has contracted with Ingenix, Inc. ( )to perform some of the functions our behalf.

Healthcare fraud and abuse is not a victimless crime. National figures indicate ten cents of every health care dollar spent is due to false billing or other illegal activity. Billions of dollars are lost each year to healthcare fraud and abuse. Fraud and abuse results in higher taxes, co-payment increases and diminished quality of care.

Health Plus is dedicated to fraud and abuse prevention and early detection. We shall abide by all fraud and abuse laws and regulations by avoiding situations or conduct that involves actual or potential fraud and abuse in our internal operations and by reporting any known or suspected fraud or abuse to the Corporate Compliance Department.

Combating fraud and abuse begins with knowledge and awareness. It is impossible to prevent fraud and abuse without understanding what fraud is and how it is committed within the health care industry. Healthcare fraud and abuse can potentially affect all aspects of health plan operations.

Definitions:
Fraud is any type of intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person in a managed care setting, including any act that constitutes fraud under applicable federal or state law, committed by an MCO, contractor, subcontractor, provider, beneficiary or enrollee or other persons. (NYCRR Title 10, Chapter II, Part 98)

Abuse is any practice that is inconsistent with sound fiscal, business, or medical practices and results in unnecessary cost to the State or federal government or MCO, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care in managed care setting, committed by an MCO, contractor, subcontractor, or provider. (NYCRR Title 10, Chapter II, Part 98)

Fraud Includes:
 
Examples of Provider Fraud:

• Billing for services not provided;
• Billing that appears to be a deliberate application for duplicate payments for the same services or unbundling, (i.e billing for separate portions, rather then for the whole procedure)
• Misrepresentations of dates, description of services or identities of members or providers;
• Billing for non-covered services as a covered services (e.g. cosmetic surgery, etc.)
• Altering medical records
• Intentional incorrect reporting of diagnoses or procedures to maximize payment (up-coding)
• Use of unlicensed staff
• Drug diversion, for example prescribing more expensive rather then indicated medication
• Accepting or giving kickbacks for member referrals
• Prescribing additional and unnecessary treatments (over-utilization)
• Waiving member co-pays
• Balance billing members for services

Examples of Member Fraud:

• Providing false information when applying for the programs or services
• Forging or selling prescription drugs
• Using transportation benefit for non-medical related business
• “Loaning” or using another’s insurance card

How To Report Healthcare Fraud and Abuse:

If you suspect health care fraud and abuse, you should report the situation to the:

Health Plus Provider Services
800-450-8753

Health Plus Member Services
800-300-8181

Be sure to have as much information as possible. The more information you have, the better the chance the case will be successfully reviewed and resolved.