Activities that are considered fraud, waste and abuse by members, practitioners or care providers hurts everyone – SHL, taxpayers, members and providers. Combating fraud, waste and abuse is the responsibility of members, healthcare providers and insurers alike. It is your responsibility to report members or other providers you suspect are committing fraud or abuse. Your assistance in notifying us and cooperating with any potential fraud or abuse occurrence is vital and appreciated in conjunction with our mutual ongoing efforts to coordinate the most effective health outcomes possible for our members.
Fraud Waste and Abuse Information
Definitions of Fraud, Waste and Abuse
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.
Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Examples of Fraud, Waste and Abuse include:
Administrative or Financial
- Falsifying credentials.
- Fraudulent credentials.
- Fraudulent enrollment practices.
- Fraudulent third party liability reporting.
- Fraudulent recoupment practices.
- Alteration of a claim.
- Incorrect coding.
- Double billing.
- False data submitted
- Billing for services or supplies not provided.
- Misrepresentation of services/supplies.
- Substitution of services.
- Resource misrepresentation (transfer and/or hiding).
- Household composition.
- Citizenship status.
- Unreported income.
- Misrepresentation of medical condition.
- Failure to report third party liability.
If you identify potential fraud, waste or abuse, please report it to us immediately so that we can investigate and respond appropriately. There are multiple reporting methods including:
SHL Provider Services - 702-242-7088
The Compliance & Ethics Help Center
–Phone: 1-800-455-4521 (US)
–The Help Center is available 24 hours a day, 7 days a week.
Health Care Fraud Tip Line – 1-866-242-7727
UnitedHealth Group Compliance & Ethics Office
Integrity of Claims, Reports and Representation to Government Entities
The Deficit Reduction Act of 2005 (DRA) was signed into law in early 2006. The DRA encourages states to have in place false claims legislation. It further requires that any entity receiving annual Medicaid payments of $5 million or more to provide written policies available to all employees, contractors and agents (including providers), detailed information about the False Claims Act and any state laws that pertain to civil or criminal penalties for making false claims and statements, and the whistleblower protection under such laws, including the role of such laws in preventing and detecting fraud, waste and abuse in federal health care programs.
A number of federal and state regulations govern information provided to the government, including the Federal False Claims Act, State False Claims Acts and other regulations and protections. SHL requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid. Federal and state governments have adopted a number of statutes to deter and punish misrepresentations with regard to health care programs. Failure to comply with these laws could result in civil and criminal sanctions imposed by government entities and SHL.
As part of an effective Compliance Program, CMS requires Medicare Advantage (MA) Organizations and Part D Plan Sponsors, including SHL, to annually communicate specific Compliance and Fraud, Waste and Abuse (FWA) requirements to their employees, including the CEO, senior administrators or managers, and for governing body members, and for first tier, downstream, and related entities” (FDRs), which include contracted physicians, health care professionals, facilities and ancillary providers, as well as delegates, contractors, and related parties.
The required education, training, and screening requirements to which we – and you – are subject include the following:
Standards of Conduct Awareness:
FDRs working on Medicare Advantage and Part D programs – including contracted providers – must provide a copy of their own or the UnitedHealth Group’s (UHG’s) Code of Conduct (found at the UnitedHealthgroup website (PDF)).
to their employees (including temporary workers and volunteers), the CEO, senior administrators or managers, governing body and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA or Part D benefits or services within 90 days of hire and annually thereafter (by the end of the year).
What You Need to Do for Standards of Conduct Awareness:
Provide your own or the UHG’s Code of Conduct as outlined above and maintain records of distribution standards (i.e. in an email, website portal or contract, etc.) for 10 years. Documentation may be requested by UnitedHealthcare or CMS to verify compliance with this requirement.
Fraud, Waste, and Abuse and General Compliance Training:
FDRs working on Medicare Advantage and Part D programs – including contracted providers – must provide Fraud, Waste, and Abuse (FWA) and General Compliance training within 90 days of employment and annually thereafter (by the end of the year) to their employees (including temporary workers and volunteers), CEO, senior administrators or managers, and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA or Part D benefits or services.
Effective January 1, 2016, CMS has amended the regulations to mandate only the use of CMS published training materials by FDRs of a contracted Medicare plan sponsor. FDRs cannot alter the published CMS training material content; however, CMS will allow FDRs to download CMS training material and add content and topics specifics to your organization. The CMS standardized FWA training and education module is available through the CMS Medicare Learning Network (MLN) at cms.gov.
FDRs meeting the FWA certification requirements through enrollment in the fee-for-service (Parts A or B) Medicare program or accreditation as durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Provider are deemed by CMS rules to have met the training and education requirements.
It is our responsibility to make sure that your organization has access to appropriate training. To facilitate that, we are providing you information on the CMS Parts C and D FWA and General Compliance training module. This module is available at the Centers for Medicare & Medicaid Services website.
What You Need to Do for FWA and Compliance Training:
Administer FWA and General Compliance training as outlined above and maintain a record of completion (i.e., method, training materials, dated employee sign-in sheet(s), employee attestations or electronic certifications from employees that include the date of the training) for 10 years. Documentation may be requested by UnitedHealthcare or CMS to verify compliance with this requirement.
FDRs must review federal exclusion lists (HHS-OIG and GSA) and state exclusion lists, as applicable, prior to hiring/contracting with employees (including temporary workers, volunteers, and consultants), the CEO, senior administrators or managers, and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA and Part D benefits or services to make sure that none are excluded or become excluded from participating in Federal health care programs.
FDRs must continue to review the federal and state exclusion lists on a monthly basis thereafter. For more information or access to the publicly accessible excluded party online databases, please see the following links:
What You Need to Do for Exclusion Checks:
Review applicable exclusion lists as outlined above and maintains a record of exclusion checks for 10 years. Documentation of the exclusion checks may be requested by UnitedHealthcare or CMS to verify that checks were completed.