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The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program. The act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment. The term "knowing" is defined to mean that a person with respect to information:
The act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted.
Health care fraud includes but is not limited to the making of intentional false statements, misrepresentations or deliberate omissions of material facts from, any record, bill, claim or any other form for the purpose of obtaining payment, compensation or reimbursement for health care services.
|By a Member|
|Using someone else’s insurance card.|
|Altering or forging a prescription.|
|Knowingly enrolling someone not eligible for coverage under their policy or group coverage.|
|Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits.|
|Altering the billed amount for services.|
|Altering the service date.|
|By a Provider|
|False coding, altering records, or claims.|
|Balance billing by asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider's usual and customary fees.|
|Billing for services not rendered or goods not provided.|
|Billing separately for services that should be a single service.|
|Billing for services not medically necessary.|
Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis.
Unbundling of procedures
Health care fraud, waste, and abuse is rising higher and higher every year. Molina and other State and Federal agencies are working together to help prevent fraud. Here are a few helpful tips on how you can help prevent health care fraud, waste, and abuse:
You may report suspected cases of fraud and abuse to Molina's Compliance Officer. You have the right to have your concerns reported anonymously to Molina and/or the California Department of Managed Health Care. When reporting an issue, please provide as much information as possible. The more information provided the better the chance the situation will be successfully reviewed and resolved. Remember to include the following information when reporting suspected fraud or abuse:
You may report fraud, waste, and abuse to Molina Healthcare through one of the following:
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