Fraud, Waste, and Abuse

OhioHealthy defines fraud, waste, and abuse as any “Suspicious Claims Activity,” which is any claim that an insurance company has reason to believe, based upon evidence, may contain one or more material misrepresentations. 

OhioHealthy further defines fraud and abuse as “Intentional deception or misrepresentation made by a person or entity with the knowledge that the deception could result in payment of an unauthorized benefit.” It may relate to providers, members, employers, brokers, or employees. 

Common types of fraud and/or abuse are as follows: 

  • Unbundling 
  • Split-billing 
  • Services not rendered 
  • Upcoding 
  • Falsification of records/bills/enrollment applications 
  • Waiving copays/deductibles 
  • Duplicate claims submissions 
  • Prescription drug switching or shorting 
  • Dispensing expired or adulterated prescription drugs 
  • Prescription drug seeking behavior, theft, forging or altering of prescriptions 
  • Identity theft 
  • Improper COB 
  • Over/underutilization 

OhioHealthy Anti-Fraud Plan is carried out through the efforts of its Special Investigations Unit (SIU). SIU is an internal investigative unit, separate from the Compliance Department, whose responsibility is to:  

  • Detect and prevent fraud, waste, & abuse in accordance with the False Claims Act. 
  • Ensure proper value of medical, behavioral health, and prescription drugs, including correct coding, reimbursement, quantity and quality. 
  • Utilize real-time systems that ensure accurate eligibility, benefits, and reimbursement. 
  • Reduce or eliminate fraudulent or abusive claims paid. 
  • Identify members with drug addiction problems. 
  • Identify and recommend providers for exclusion from the network as a result of fraudulent or abusive practices. 
  • Identify fraud on employer group enrollment applications. 
  • Refer potential FWA cases to the appropriate authorities (CMS, MEDIC, MFCU, law enforcement, etc.) and conduct case development and support activities for those investigations. 
  • Prevent illegal activities and assist law enforcement by providing information needed to develop successful prosecutions. 

Federal False Claims Act 

The Federal False Claims Act's primary use is to combat fraud & abuse in government healthcare programs. The Act accomplishes this by making it possible for the government to bring civil actions to recover damages and penalties when healthcare providers submit false claims. Penalties can include up to three times actual damages and an additional $5,500 to $11,000 per false claim.  

The False Claims Act prohibits, among other things: 

  • Knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval; 
  • Knowingly making or using, or causing to be made or used, a false record or statement in order to have a false or fraudulent claim paid or approved by the government; 
  • Conspiring to defraud the government by getting a false or fraudulent claim allowed or paid; and 
  • Knowingly making or using, or causing to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government. 

“Knowingly” means that a person, with respect to information: 1) has actual knowledge of the information; 2) acts in deliberate ignorance of the truth or falsity of the information; 3) acts in reckless disregard of the truth or falsity of the information. 

The False Claims Act also contains a qui tam or “whistleblower” provision. This provision allows a private person with knowledge of a false claim to bring a civil action on behalf of the Commonwealth or Federal Government. The qui tam provision also protects a whistleblower from retaliation by his employer. This applies to any employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in his employment as a result of the employee's lawful acts in furtherance of a false claims action. 

Virginia also has a False Claims Act that mirrors the federal False Claims Act. 

Providers contracted with OhioHealthy will agree to be bound by and comply with all applicable Ohio and federal laws and regulations. Any violation by the practice or by any practice physician shall be grounds for termination. 

Providers contracted with OhioHealthy will also comply as follows: 

  • Provider agrees to comply with all non-discrimination requirements set forth in the contract. 
  • Practice agrees to provide access to its premises and to its contracts and/or medical records, to representatives of OhioHealthy, as well as duly authorized agents or representatives of the Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the State Medicaid Fraud Unit in accordance with their contract. 
  • Practice agrees otherwise to preserve the full confidentiality of medical records in accordance with their contract. 
  • Practice agrees to ensure confidentiality of family planning services in accordance with the contract.  

If you or someone you know has knowledge of a health insurance claim submitted to OhioHealthy that may meet the above definition of a “suspicious claims activity,” or suspect any provider, enrollee or employee of OhioHealthy may be committing fraudulent or abusive practices, please forward all the pertinent information to OhioHealthy's SIU for further investigation at the address below. 

Your complaint will be investigated and a thorough follow-up will be undertaken, including possible follow-up with you if additional questions arise. All referrals made to the SIU may remain anonymous. Please be sure to leave your name and number if you wish to be contacted for follow up. If appropriate, the necessary governmental agency (DMAS, CMS, OIG, BOI, etc.) will be notified as required by law.