Magellan Health

For Providers

Fraud, Waste & Abuse/Compliance

Magellan Behavioral Health of Pennsylvania (Magellan) takes provider fraud, waste and abuse seriously. Magellan promotes provider practices that are compliant with all federal and state laws. Our expectation is that providers will submit accurate claims, not abuse processes or allowable benefits, and exercise their best independent judgment when deciding which services to order for their patients.

Magellan does not tolerate fraud, waste or abuse, either by providers or staff. Accordingly, we have instituted extensive procedures to combat these problems. These procedures are wide-ranging and multi-faceted, focusing on education, prevention, detection and investigation of all types of fraud, waste and abuse in government programs.

Our policies in this area reflect that both Magellan and providers are subject to federal and state laws designed to prevent fraud and abuse in government programs (e.g. Medicaid and Medicare). Magellan complies with all applicable laws, including the Federal False Claims Act, state false claims laws, applicable whistleblower protection laws, the Deficit Reduction Act of 2005, the American Recovery and Reinvestment Act of 2009, the Patient Protection and Affordable Care Act of 2010 and applicable billing requirements for state and federally funded health care programs.

 

Understanding Fraud, Abuse, Waste and Overpayment:

 

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/her or some other person. It includes any act that constitutes fraud under applicable federal or state law.


Examples include:

  • Intentionally billing for services that were not provided
  • Falsifying signatures
  • Rounding up time spent with a member
  • Altering claim forms


Abuse
means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to government-sponsored programs, and other health care programs/plans, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to federally and/or state-funded health care programs.


Examples include:

  • Services that are billed by mistake
  • Misusing codes: code on claim does not comply with national or local coding guidelines; not billed as rendered
  • Billing for a non-covered service
  • Providing services in a method that conflicts with regulatory requirements (e.g., exceeding the maximum number of patients allowed per group session)
  • Retaining and failing to refund and report overpayments (e.g., if your claim was overpaid, you are required to report and refund the overpayment, and unpaid overpayments also are grounds for program exclusion)


Waste
means over-utilization of services or other practices that result in unnecessary costs.

 
Examples include:

  • Using excessive services such as office visits
  • Providing services that aren’t medically necessary
  • Provider ordering excessive testing


Overpayment
means any funds that a person receives or retains under Medicare, Medicaid, SCHIP and other government funded health care programs to which the person, after applicable reconciliation, is not entitled under such health care program. It includes any amount that is not authorized to be paid by the health care program.


Examples include:

  • Inaccurate or improper cost reporting
  • Improper claiming practices
  • Fraud
  • Abuse          

 

Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) has established its own local Compliance Department to support providers in their oversight of fraud, waste & abuse. Our distinctive approach includes auditing activities (routine and targeted); and providing education, technical assistance and resources to support our provider network.

 

The links below will direct you to additional Compliance-related information:

 

Preparing for an Audit

 
Trainings / Education

 
Fraud, Waste, & Abuse Resources


Making a Fraud, Waste & Abuse Referral


Audit Trends


Compliance Best Practices

 

Confidentiality Resources

 

 

 



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Contact Information

Member Services:
Bucks County: 877-769-9784
Cambria County: 800-424-0485
Delaware County: 888-207-2911
Lehigh County: 866-238-2311
Montgomery County: 877-769-9782
Northampton County: 866-238-2312

Provider Services:
Bucks/Montgomery: 877-769-9779
Cambria County: 800-424-3711
Delaware County: 800-686-1356
Lehigh/Northampton: 866-780-3368

Hearing Impaired Lines (TTY):
Bucks County TTY: 877-769-9785
Cambria County TTY: 877-769-9785
Delaware County TTY: 888-207-2910
Montgomery County TTY: 877-769-9783
Lehigh County TTY: 866-238-2313
Northampton County TTY: 866-780-3367
AfterHours TTY (6:00p - 8:00a): 800-787-1730

Fraud & Abuse: 800-755-0850

For emergency situations always call 911

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