Fraud, Waste, and Abuse

Defining fraud, waste, and abuse

Select Health of South Carolina receives state and federal funding for payment of services provided to our members. In accepting claims payment from the plan, health care providers are receiving state and federal program funds and are therefore subject to all applicable federal and/or state laws and regulations relating to this program.

Violations of these laws and regulations may be considered fraud or abuse against the Medicaid program. Providers are responsible for knowing and abiding by all applicable state and federal laws and regulations.

Fraud

Fraud is when a person knowingly provides false and/or misleading information to obtain some benefit for themselves or some other person that they are not eligible for. Providers should be aware of applicable federal and state laws, which detail specific acts that constitute fraud.

Waste

Waste is an overutilization of services or other practices that results in preventable costs. Waste is not considered to be caused by criminally negligent actions, but rather is the misuse of resources.

Abuse

Abuse consists of practices that do not make sense from a financial, business, or medical standpoint and which cause federally funded programs to provide unnecessary funds. This may be done by recipients (members) or providers, and it includes the provider or recipient being reimbursed for medically unnecessary services or services that do not meet the standards of the federally funded program providing the reimbursement.

Examples of fraud, waste, and abuse

Provider fraud, waste, or abuse include but are not limited to:

• Billing for services not furnished.
• Submitting false information to obtain authorization to furnish services or items to Medicaid recipients.
• Accepting kickbacks for patient referrals.
• Violating physician self-referral prohibitions.
• Billing for a more costly service than the one performed.
• Providing, referring, or prescribing services or items that are not medically necessary.
• Providing services that do not meet professionally recognized standards.

Examples of member fraud, waste, or abuse

Member fraud, waste, or abuse include but are not limited to:

• Fraudulent activities (forged/altered prescriptions or borrowed cards).
• Repetitive emergency room visits with little or no PCP intervention or follow-up.
• Same/similar services or procedures in an outpatient setting within one year.
• A member using someone else’s insurance card to receive care.
• Forging or altering prescriptions/medications, trafficking SNAP benefits, or taking advantage of the system in any way.

If upon review by Select Health there is an indication of recipient misuse, abuse, or fraud, the member will be placed on the Recipient Restriction Program, which means the member(s) can be restricted to a single PCP, pharmacy, or hospital/facility for a period of five years.

Restriction to one network provider of a particular type will help ensure coordination of care and facilitate more focused medical management.

Screening employees for federal exclusion

All individuals and entities whose functions are a necessary component of providing items and services to Medicaid recipients, and who are involved in generating a claim to bill for services or are paid by Medicaid, should be screened for exclusion from the federal health care programs before you employ and/or contract with them. If hired, they should be rescreened on an ongoing monthly basis to capture exclusions and reinstatements that have occurred since the last search. Examples of individuals or entities that providers should screen for exclusion include but are not limited to:

• An individual or entity who provides a service for which a claim is submitted to Medicaid.
• An individual or entity who causes a claim to be generated to Medicaid.
• An individual or entity whose income derives all or in part from Medicaid funds, directly or indirectly.
• Independent contractors if they are billing for Medicaid services.
• Referral sources, such as providers who send a Medicaid recipient to another provider for additional services or a second opinion related to a medical condition.

Medicaid providers who employ or enter into contracts with individuals or entities to provide items or services to Medicaid recipients when those individuals or entities are excluded from participation in any Medicare, Medicaid, or other federal health care programs are subject to termination of their enrollment in and exclusion from participation in the Medicaid program and all federal health care programs, recoupment of overpayments, and imposition of civil monetary penalties.

View the list of excluded individuals/entities (LEIE) database.

The System for Award Management (SAM) is an official website of the U.S. government. Search for entity registration and exclusion records.

Additional resources

Waste and recovery

Examples of waste include but are not limited to:

• Overpayment due to incorrect set-up or update of contract/fee schedules in the system.
• Overpayments due to claims paid based upon conflicting authorizations or duplicate payments.
• Overpayments resulting from incorrect revenue/procedure codes or retroactive third-party liability/eligibility.

The Payment Integrity Department is responsible for identifying and recovering claim overpayments. The department performs several operational activities to ensure the accuracy of providers’ billing submissions. The department utilizes internal and external resources to prevent the payment of claims associated with waste and to initiate recovery when overpaid claims are identified.

As a result of these claims accuracy efforts, providers may receive letters from Select Health or on behalf of Select Health, regarding recovery of potential overpayments and/or requesting medical records for review.

Please refer to our Provider Manual or the letter you received to learn how to return overpayments. You should also use the contact information provided in the letter to expedite a response to questions or concerns.　

References and training

• Centers for Medicare & Medicaid Services: Fraud & abuse