Medicare Compliance

Meridian Medicare-Medicaid Plan

Each year, healthcare fraud costs taxpayers billions of dollars. It drives up the cost of health care and puts a burden on taxpayers and the healthcare system. Healthcare fraud can take on many forms, from small infractions to multi-million dollar schemes. It can also occur anywhere, from small rural towns to major metropolitan cities.

How to Report Fraud

If you believe you have seen any of these activities, you can contact us immediately at 1-866-364-1350 (TTY: 711), Monday - Sunday from 8 a.m. to 8 p.m. We will conduct a thorough investigation and work with State and Federal government agencies to make sure your rights and services are protected to the fullest extent. You may also visit our FWA Reporting Site at http://mhplan.ethicspoint.com.

Examples of Fraud

At MeridianCare, we are committed to doing our part to stop healthcare fraud. You can also do your part in fighting against healthcare fraud by protecting yourself against fraudulent claims and practices.

Here are some examples of activities you should look for:

Does your Explanation of Benefits (EOB) show a charge that you did not receive?
Does your provider bill for services not provided?
Is your provider rendering unnecessary services?
Is your provider prescribing a higher quantity than is medically necessary for a condition?
Did a sales agent call you or show up at your residence without your permission to market a Medicare Advantage product or service?
Did you get a phone call from an unknown caller offering low cost or free medical services? Did the caller ask for your personal information, such as your Social Security number, Medicare number or date of birth?
Do you know someone who changed or forged a prescription?
Do you know a provider who primarily writes for narcotics or controlled substances?
Do you know someone who visits multiple doctors to get the same prescription?
Do you know someone who fills a prescription and then sells the medication?
Are medications you picked up expired, fake or diluted?
Did you pharmacy give you generics when your prescription requires that a brand be dispensed?
Does your pharmacist provide less than the prescribed quantity and bill for the full amount?
Did you incur a claim for prescriptions that you never picked up?

Resources

There are many resources available to help you stay informed of fraudulent activities and give you tips on how to protect yourself from them. This is just a short list of some of these resources.

Report Fraud & Abuse: This government website provides information on Medicare fraud, including examples and how to detect and report them.
Identity Theft: This government website provides information on identity theft and how to prevent it.
4R (PDF): This government document provides tips on how to spot Medicare fraud.
Protecting Yourself & Medicare from Fraud (PDF): This government document provides tips on how to spot Medicare fraud.
Quick Facts about Medicare Plans & Protecting Your Personal Information (PDF): This government document provides information on inappropriate Medicare health plan activities.
US Department of Justice: This government website provides news and updates on national health care fraud.
Office of Inspector General: This government website provides news and updates on national health care fraud.

Privacy Practices

MeridianComplete Providers, Vendors, Business Partners, or Sales Agents

Each year, healthcare fraud costs taxpayers billions of dollars. It drives up the cost of health care and puts a burden on taxpayers and the healthcare system. As an entity that does business with MeridianCare, you have a duty to prevent, detect and correct noncompliance and fraud, waste and abuse (FWA).

Reporting

If you suspect noncompliance or FWA activities, you must report them to your MeridianCare contract administrator. You may also report anonymously 24/7 at 1-866-364-1350 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m. You may also visit our FWA Reporting Site at http://mhplan.ethicspoint.com.

Examples of Noncompliance and FWA

Here are some common examples of noncompliant and FWA activities:

Providers & Pharmacies:

Submitting claims when you are on the Office of Inspector General's (OIG) exclusion list
Billing multiple payers for the same service, except as required for coordination of benefit
Inappropriate up-coding
Billing for services not rendered
Providing excessive or unnecessary services
Prescription forging or altering
Receiving illegal payments or other benefits to prescribe certain medications
Prescription drug shorting
Providing false or misleading information to justify coverage
Dispensing expired or adulterated prescription drugs
Illegal distribution of free samples
Billing for non-covered services as covered
Stolen prescriber Drug Enforcement Agency (DEA) number or prescription pad
Not meeting your contractual performance standards
Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule

Sales Agents:

Using marketing materials not approved by MeridianCare or the Centers for Medicare and Medicaid (CMS)
Using high pressure sale tactics
Using deceptive and misleading sale tactics
Selling or marketing when you are not licensed or appointed
Making unsolicited contacts with beneficiaries
Not meeting your contractual performance standards
Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule

Administrative Business Partners:

Doing Medicare work when you are on the Office of Inspector General's (OIG) exclusion list
Not meeting your contractual performance standards
Not providing annual compliance and FWA training to your employees
Not overseeing the work of your subcontractors

Compliance and FWA Training

You and your employees are required to take the training annually. For your convenience, we have provided you with the following training materials.

You must ensure that all of your employees and any downstream entity (i.e., subcontractor) take this CMS-approved training module annually and read our Compliance Program & Standards of Conduct. All new employees and any downstream entity (i.e., subcontractor) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log (PDF) to track your completion.

If your employees have taken compliance training for other Medicare Advantage plans (through similar CMS-approved training modules) or through CMS' Medicare Learning Network (MLN) website, you do not have to re-take this training. However, you must still be familiar with our Compliance Program & Standards of Conduct, since they pertain to our company specifically. Also, if you are a medical provider and have met the most recent fraud, waste and abuse (FWA) certification requirements through enrollment into the Original Medicare program, as required by Medicare, you do not have to take Module I. FWA Training. However, they must still document their completion using the other health plan's Training Attendance Log or a modified version thereof. You do not need to send anything to us. However, your proof of training attendance and completion will be subject to audit and verification.