PAM Section 10: Special Investigations Unit

On this page: 

• Fraud, Waste and Abuse (FWA)
• What is Fraud, Waste and Abuse?
• Examples of Provider, Pharmacy, or Vendor FWA 
• Disclosure of Ownership, Exclusion and Criminal Conviction
• How to Report FWA

Fraud, Waste and Abuse (FWA)

In order to be good stewards of Medicare funds, as well as keep costs low for our members, Trinity Health Plan Of New England is committed to program integrity efforts by early identification, correction and prevention of health care FWA through its Special Investigations Unit (SIU).

Trinity Health Plan Of New England’s SIU utilizes various methods in its efforts to address FWA including, but not limited to, software and data analytics tools. These resources assist in detecting claim aberrancies, outlier behavior, over/under-utilization and potentially inappropriate billing practices.

Procedures are in place to promptly address non­compliance and potential FWA issues, as well as reporting identified issues to appropriate authorities. Investigative and corrective steps by the SIU may include things such as interviews, medical record reviews, verbal/written provider education, written and documented corrective action plans, recovery of funds, appropriate federal and state law enforcement/ MEDIC referrals or other legal action.

The provider shall give the SIU the right to audit, evaluate and inspect books, contracts, documents, papers, medical records, patient care documentation and any other records of provider, its downstream and related entities or its transferee, that pertain to any aspect of services performed for members, reconciliation of benefit liabilities and determinations of amounts payable under the contract between CMS and Plan or as the Secretary of Health and Human Services (HHS) may deem necessary for ten (10) years or the date of completion of an audit, whichever is later.

What is Fraud, Waste and Abuse?

Fraud

• Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist.
• Knowingly solicit, pay and/or accept payment to induce or reward referrals for items or services reimbursed by federal health care programs.
• Making prohibited referrals for certain designated health services.
• Requires intentional deception or misrepresentations made by someone with the knowledge that the deceptions could result in unauthorized benefits or payments that they would not have been otherwise entitled to. This could include a false statement, misrepresentation, deliberate omission of facts or information that is critical in making a determination of whether a benefit is payable.

Waste

Typically defined as the overutilization or misuse of services or practices which, either directly or indirectly, result in unnecessary costs.

Abuse

Practices that are inconsistent with sound fiscal, business or medical practices and result in unnecessary costs. These could include services which are not medically necessary or fail to meet professionally recognized standards of care or result in improper payments. In addition, abuse can involve charging excessively for services or supplies or up-coding for services provided. In such abuse situations, a knowing or intentional misrepresentation of statement or fact is not necessary to obtain the payment.

Examples of Provider, Pharmacy or Vendor FWA

• Prescribing medications or supplies which are not medically necessary. Ordering medically unnecessary testing. Billing for services not rendered. Employing excluded individuals.
• Engaging in kickback arrangements. Misrepresenting services provided in order to receive higher reimbursement.
• Dispensing drugs purchased outside the U.S. Dispensing generic drugs but billing for brand. Intentionally dispensing less than the prescribed quantity (shorting). Billing for prescriptions not received by the member or not filled.

Disclosure of Ownership, Exclusion and Criminal Conviction

Trinity Health Plan Of New England conducts monthly reviews of exclusion lists, including the HHS Officer of Inspector General, List of Excluded Individuals and Entities, the CMS Preclusion List of prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries, General Services Administration and the System for Award Management database of parties that are excluded from federal procurement, to ensure that no federal funds are used to pay for services, equipment, or drugs provided by a provider, supplier, employee or FDR who is excluded. If a provider or supplier is found to be on an exclusion list, the Plan may take action, including termination as a participating provider with Trinity Health Plan Of New England.

How to Report FWA

We are committed to partnering with you! If you suspect someone of committing fraud, please report any suspicious fraudulent activity in one of these ways:

• Leave a voicemail for Trinity Health Plan Of New England’s Special Investigations Unit at 1-614-546-4392 Toll free number: 1-833-263-4863
• Email Trinity Health Plan Of New England’s Special Investigations Unit directly at: SIU.MediGold@mchs.com.
• Send a fax to Trinity Health Plan Of New England’s Special Investigations Unit at: 1-833-900-0606.

If you prefer, you may report fraud anonymously by:

• Completing a report online through our anonymous Special Investigations Unit form.
• Calling our parent company’s (Trinity Health) anonymous Integrity Hotline at 1-866-477-4661. Please indicate you would like to report fraud, waste or abuse concerning Trinity Health Plan Of New England.
• Reporting fraud via U.S. Mail:

Trinity Health Plan Of New England Special Investigations Unit 
3100 Easton Square Place 
Third Floor – Health Plan 
Columbus, Ohio 43219