FRAUD AND ABUSE
To report suspected fraud or abuse of the Louisiana
visit the DHH Medicaid Site Fraud and Abuse Page.
To maintain the integrity of Louisiana Medicaid, providers must understand and follow Louisiana Medicaid's policy concerning fraud and abuse. The following lists the different types of fraud and abuse and sets forth specific sanctions for providers who commit fraud and who abuse Medicaid.
Federal regulations require that Louisiana Medicaid establish criteria that are consistent with principles recognized as affording due process of law for identifying situations where there may be fraud or abuse, for arranging prompt referral to authorities, and for developing methods of investigation or review that ascertain the facts without infringing on the legal rights of the individuals involved.
A matter of law rather than of ethics or abuse of privilege. The definition of fraud that governs between citizens and government agencies is found in Louisiana R.S. 14:67 and Louisiana R.S. 14:70.01. Legal action may also be mandated under Section 1909 of the Social Security Act as amended by Public Law 95-142 (HR-3).
Prosecution for fraud and the imposition of a penalty, if the individual is found guilty, are prescribed by law and are the responsibility of the law enforcement officials and the courts. All such legal action is subject to due process of law and to the protection of the rights of the individual under the law.
Provider Fraud - Cases involving one or more of the following situations shall constitute sufficient grounds for a provider fraud referral:
Billing for services, supplies, or equipment which are not rendered to, or used for, Medicaid patients;
Billing for supplies or equipment which are clearly unsuitable for the patient's needs or are so lacking in quality or sufficiency for the purpose as to be virtually worthless;
Claiming costs for non-covered or non-chargeable services, supplies, or equipment disguised as covered items;
Materially misrepresenting dates and descriptions of services rendered, the identity of the individual who rendered the services, or of the recipient of the services;
Duplicate billing of the Medicaid Program or of the recipient, which appears to be a deliberate attempt to obtain additional reimbursement; and
Arrangements by providers with employees, independent contractors, suppliers, and other, and various devices such as commissions and fee splitting, which appear to be designed primarily to obtain or conceal illegal payments or additional reimbursement from Medicaid.
Recipient Fraud - Cases involving one or more of the following situations constitute sufficient grounds for a recipient fraud referral:
The misrepresentation of facts in order to become or to remain eligible to receive benefits under Louisiana Medicaid or the misrepresentation of facts in order to obtain greater benefits once eligibility has been determined;
The transferring (by a recipient) of a Medicaid Eligibility Card to a person not eligible to receive services under Louisiana Medicaid or to a person whose benefits have been restricted or exhausted, thus enabling such a person to receive unauthorized medical benefits; and
The unauthorized use of a Medicaid Eligibility Card by a person not eligible to receive medical benefits under Medicaid.
Abuse of Louisiana Medicaid by either providers or recipients includes practices which are not criminal acts and which may even be technically legal, but which still represent the inappropriate use of public funds.
Provider Abuse - Cases involving one or more of the situation listed below constitute sufficient grounds for a provider abuse referral:
- The provision of services that are not medically necessary;
- Flagrant and persistent overuse of medical or paramedical services with little or no regard for the patient's medical condition or needs or for the doctor's orders;
- The unintentional misrepresentation of dates and descriptions of services rendered, of the identity of the recipient of the services, or of the individual who rendered the services in order to gain a larger reimbursement than is entitled; and;
- The solicitation or subsidization of anyone by paying or presenting any person money or anything of value for the purpose of securing patients (Providers, however, may use lawful advertising that abides by BHSF rules and regulations).
Recipient Abuse - Cases involving one or more of the following situation constitute sufficient grounds for a recipient abuse referral.
- Unnecessary or excessive use of the prescription medication benefits of Louisiana Medicaid;
- Unnecessary or excessive use of the physician benefits of the program, and;
- Unnecessary or excessive use of other medical services and/or medical supplies that are benefits of the program.
Fraud and Abuse Detection
The first step in the fraud and abuse process is a referral of the suspect claim to a review board.
Referrals - Situations involving potential fraud and/or abuse which are to be followed up for review by Louisiana Medicaid may include any or all of the following:
- Cases referred by the U.S. Department of Health and Human Services - Louisiana Medicaid in turn refers suspected cases of fraud in the Medicare Program to the Center for Medicare and Medicaid Services (CMS) and works closely with that agency in such matters;
- Situations brought to light by special review, internal controls, provider audits or inspections; and/or
- Referrals from other agencies or sources of information.
Recipient Verification Notices
The federal regulations (Public Law 92-693, Sec. 253 3) for MMIS require that Louisiana Medicaid provides prompt written notice of medical services which are covered to the recipients of these services. The information contained in the notice includes the name of the person(s) furnishing medical services, the date on which the services were furnished, and the amount of payment required for the services. A predetermined percentage of the recipients who have had medical services paid on their behalf during the previous month will receive the required notice, that is, the Recipient's Explanation of Medical Benefits (REOMB). Periodically, Louisiana Medicaid may send notices to 100% of the recipients receiving services from any provider for any given period.
Surveillance Utilization Review
The Surveillance Utilization Review (SUR) Department, operated by Molina Medicaid Solutions in partnership with the Department of Health and Hospitals - Office of Program Integrity, reviews provider compliance with the policies and regulations of the Louisiana Medicaid Program. Providers with service profiles which fall outside excepted norms are reviewed by skilled medical staff using the personal computer-based Surveillance and Utilization Review System (SURS).
Providers should anticipate an audit during their association with the Medicaid Program. When audited, providers should cooperate with the representatives of DHH, which includes Molina, in accordance with their participation of agreement signed upon enrollment. Failure to comply with program regulations can result in mild to severe administrative sanctions, which include, but are not limited to:
- Withholding of Medicaid payments;
- Referral to the Attorney General's Office for investigation, and;
- Termination of Provider Agreement.
Providers are reminded that a service undocumented is considered a service not rendered. Providers should ensure their documentation is accurate and complete. All undocumented services are subject to recoupment. Other services subject to recoupment are:
- Upcoding on level of care;
- Maximizing payments for services rendered;
- Billing components of lab tests, rather than the appropriate lab panel;
- Billing for medically unnecessary services;
- Consults performed by the patient's primary care, treating, or attending physicians;
- Billing for services not rendered, and;
- Inappropriate use of provider number by unauthorized users.
Fraud and Abuse Hotline
The State has created a hotline for reporting possible fraud and abuse in the Louisiana Medicaid Program. Anyone can report concerns to this number. The number is (800) 488-2917.
Providers are encouraged to give this phone number to any individuals or providers who want to report possible cases of fraud or abuse.