Provider Manual

Fraud, Waste & Abuse/Compliance

This section defines the meaning of and describes Commonwealth Care Alliance's protocols regarding fraud, waste, and abuse.

Commonwealth Care Alliance's Fraud, Waste and Abuse Program

Commonwealth Care Alliance has created a program in order to prevent, identify, combat, and report fraud, waste and abuse. Commonwealth Care Alliance looks to its contracted Providers to assist in identifying and reporting fraud, waste, and abuse. A critical component to Commonwealth Care Alliance's Program is abiding by federal and state laws and regulations that apply to fraud, waste, and abuse.

How to Report a Suspected Case of Fraud, Waste or Abuse

If you suspect an instance of fraud, waste, or abuse related to a Commonwealth Care Alliance member or program, please contact your Commonwealth Care Alliance contact or Commonwealth Care Alliance's Fraud, Waste or Abuse Prevention Coordinator directly at (617) 426-0600.

Definitions

Fraud: - The intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.
Waste: - The unintentional or intentional, thoughtless or careless expenditures, consumption, mismanagement, use or squandering of Commonwealth Care Alliance's, Federal or MassHealth resources to the detriment of Commonwealth Care Alliance, Federal or Commonwealth funded programs. Waste also includes incurring unnecessary costs because of inefficient or ineffective practices, systems, or controls.
Abuse: - Practices that are inconsistent with sound fiscal, business or medical practices and result in unnecessary costs to government programs or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in an unnecessary cost to the Medicare/MassHealth programs.

Examples

Examples of fraud, waste, or abuse may include billing for services not performed, performing unnecessary services and tests, double billing, misuse of membership card, up-coding, altering medical records, use of unlicensed staff, members selling their prescription drugs and falsification of healthcare provider credentials.

For a summary, please read the Deficit Reduction Act, the Federal False Claims Act, and the Massachusetts False Claims Law.

Compliance Hotline

Providers are advised that Commonwealth Care Alliance's Compliance Hotline is available to report any Commonwealth Care Alliance related compliance concerns or questions. The Compliance Hotline is a confidential and anonymous avenue for reporting a compliance concern. The number is 1-800-826-6762.

Policies and Procedures

Commonwealth Care Alliance's policies and procedures are available to providers upon request. If a provider would like access to a policy and procedure, the provider should contact Commonwealth Care Alliance's Compliance Officer at (617) 426-0600.

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Last Updated 1/19/12

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