Provider Resources

Fraud, Waste & Abuse/Compliance

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 

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 

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 

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 

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          

The links below will direct you to additional Compliance-related information. In addition to these resources, click here to view all of our recent compliance alerts.

Preparing for an Audit

Trainings / Education

Fraud, Waste, & Abuse Resources

Making a Fraud, Waste & Abuse Referral

Audit Trends

Compliance Best Practices

Confidentiality Resources

 

The Adobe Reader is required to view PDF files.