Fraud, Waste and Abuse

In accordance with Centers for Medicare and Medicaid Services (CMS) regulations, Medicare Advantage organizations (MAOs) are required to establish, implement and ensure that all first-tier, downstream and related entities (FDRs) have taken the following trainings, and reviewed the Code of Business Conduct and Ethics, and Medicare Compliance Policies and Procedures, in order to prevent fraud and unethical behavior: 

  • Medicare Part C and D Fraud, Waste and Abuse Training 
  • Issue Identification, Tracking, Escalation, and Resolution Training 

MEDICARE PARTS C AND D FRAUD, WASTE, AND ABUSE TRAINING

CMS has launched the Medicare Parts C and D Fraud, Waste and Abuse (FWA) Training through the CMS Medicare Learning Network (MLN) website at www.cms.gov/MLNProducts > MLN Provider Compliance > Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training. Delegated participating physician groups (PPGs), independent practice associations (IPAs) and medical groups can also use this training module to satisfy the CMS training requirement for their administrative staff including all staff members who have involvement in the administration or delivery of Part C and D benefits. Health Net and MHN will continue to randomly conduct audits to ensure compliance with this requirement.

Record Maintenance and Attestation Requirements for Training

Delegated PPGs, IPAs and medical groups are accountable for maintaining records for a period of 10 years of the time, attendees, topic, certificates of completion (if applicable), and test scores of any tests administered to their employees related to FWA and general compliance training. This is subject to audit upon request from Health Net, MHN or CMS. 

CODE OF BUSINESS CONDUCT AND ETHICS, AND MEDICARE COMPLIANCE POLICIES AND PROCEDURES

Health Net’s Code of Business Conduct and Ethics establishes the standards that reflect Health Net/MHN’s reputation as an ethical company. When making decisions about coverage, treatment plans or other services, Health Net and MHN apply the highest standards of professional ethics with respect for the autonomy, dignity, privacy, and rights of our members. Health Net’s Code of Business Conduct and Ethics is accessible through the Health Net provider website at www.healthnet.com/provider > Contractual and Clinical Resources > Medicare Compliance Regulations > Code of Business Conduct and Ethics.

The Code of Business Conduct and Ethics should be made available to all staff. Firsttier entities may download and distribute the Code of Business Conduct and Ethics to their downstream providers. Health Net expects all Health Net and MHN providers, as well as FDRs to read and understand Health Net standards of conduct and report any suspected violations of those standards. Participating providers and FDRs who have their own code of business conduct and ethics and comparable policies and procedures, or that adopt another MA or MA Part D (MA-PD) plan’s code of business conduct or policies and procedures, are subject to review upon request from Health Net, MHN or CMS. Health Net’s Medicare compliance policies and procedures are accessible through the Health Net provider website at www.healthnet.com/provider > Contractual and Clinical Resources > Medicare Compliance Regulations > Medicare Fraud, Waste and Abuse Training. 

HEALTH CARE FRAUD

Health care fraud contributes to the rising cost of health insurance, reduces the amount of funds available to pay honest providers, and increases premiums to employers and members. Health Net investigates allegations of FWA and reports of noncompliance at every level. Below are examples of health care fraud and unethical or noncompliant activities:

  • Consumer health care fraud: Filing claims for services or medications not received, forging or altering bills or receipts, or using someone else's coverage or insurance card.
  • Provider health care fraud: Billing for services not actually performed, falsifying a patient's diagnosis to justify tests, surgeries or other procedures that are not medically necessary, or upcoding – billing for a more costly service than the one actually performed 
  • Unethical or noncompliant activities: Falsifying or tampering with company documents or records, accepting gifts or favors that may influence a business decision, violating Health Net’s Code of Business Conduct and Ethics, or accessing personal information or protected health information (PHI) without authorization.

REPORTING FRAUD, WASTE, ABUSE, OR VIOLATIONS OF STANDARDS OF CONDUCT

Health Net and MHN have adopted processes to receive, record and respond to compliance questions, reports of potential or actual noncompliance, and FWA from contractors, agents, directors, enrollees, and FDRs. Health Net and MHN maintain confidentiality to the extent possible, allows callers to remain anonymous if desired and ensure non-retaliation against those who report suspected misconduct. To report suspected fraud, waste or abuse, contact Health Net as listed below:

Health Net, Inc. Special Investigations Unit
PO Box 2048
Rancho Cordova, CA 95741-2048
Health Net’s Fraud Hotline: (800) 977-3565

To report potential or actual noncompliance or ethical concerns, contact Health Net as listed below:

Health Net Medicare Compliance Officer
Gay Ann Williams
Mail Stop: CA-102-22-07
21650 Oxnard Street
Woodland Hills, CA 91367
Health Net’s Integrity Line: (888) 866-1366 

ADDITIONAL INFORMATION

If you have questions regarding the information contained in this update, contact MHN Professional Relations at: MHN.ProviderServices@Healthnet.com.