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QUEST Integration – Fraud

Original Effective Date:

05/01/2007

Current Effective Date:

01/01/2015

I. Definition

QUEST Integration fraud, waste, or abuse (FWA) depletes valuable public funds meant to provide healthcare and services to low-income and vulnerable citizens in Hawaii. QUEST Integration health plans are funded by Federal and State tax dollars. You can assist in fighting FWA by reporting potentially suspicious behavior or incidents.

The Health Insurance Accountability and Portability Act (HIPAA) makes it a federal offense to submit fraudulent claims to any healthcare plan.

The following are examples of FWA:

  1. Providing and billing for medically unnecessary services
  2. Billing for services not provided
  3. Billing for a higher level of service than was actually provided (upcoding)
  4. Billing separately for services that should be a single service (unbundling)
  5. Falsifying medical records in order to receive higher reimbursements
  6. Persons using a member’s insurance card to obtain services, with or without the knowledge of the cardholder

II. HMSA’s Investigation of Potential FWA

  1. HMSA’s SIU is dedicated to preventing, identifying, investigating, and taking action against FWA HMSA identifies potential fraud through a variety of means including:
    1. Complaints and tips from members, providers, member of the community and internal staff
    2. Information provided from law enforcement
    3. Cases proactively developed through claims data analysis and fraud detection software
  2. In cases involving provider billings, HMSA may:
    1. Request and review a provider’s medical records
    2. Review claims retrospectively
    3. Meet with provider and/or provider staff
    4. Follow-up to determine whether:
      1. Billings for the services were appropriate
      2. The provider was correctly paid for services rendered
  3. Some cases reviewed by HMSA do not result in a finding of potential FWA
  4. HMSA will seek to recover any overpayments that are identified as the result of improper billings or payments

III. When FWA is Identified

  1. When FWA is identified, the SIU may proceed with a breadth of administrative actions; including, but not limited to:
    1. Recovery of Overpayments
    2. Referrals to Credentialing Committee and Referrals to Patient Safety Committee
    3. Ongoing Monitoring/Claim Suspension and Reviews
    4. Onsite Audits
    5. Payment Termination
    6. De-credentialing/Contract Termination
  2. The SIU may also refer instances of FWA to the following external entities, which could result in possible criminal investigation:
    1. Medical Board
    2. Law Enforcement (Federal Bureau of Investigation, Drug Enforcement Administration, etc.)
    3. Regulatory Entities (Medicaid Investigations Division, Office of Inspector General (HHS-OIG)

IV. Provider Steps to Prevent and Report FWA

  1. There are a number of things providers can do to prevent FWA and protect themselves from being the subject of an investigation, including:
    1. Monitoring billings to confirm that staff are properly billing for the services provided.
    2. Checking patient identification (e.g., driver's license, state ID card) for new patients to the practice against the insurance card presented, prior to rendering services.
    3. Keeping complete medical records that are legible and accurately document the services provided.
    4. Providing ongoing education to staff regarding proper documentation and billing practices.
  2. The SIU encourages anyone who observes instances of potential Medicaid FWA to contact our confidential FWA Hotline at 808-948-5166 (Oahu) or 1-888-398-6445 toll-free from the Neighbor Islands and out of state.

  3. Reports of suspected FWA can also be mailed to:

    HMSA

    Special Investigations Unit, 10600

    P. O. Box 860

    Honolulu, HI  96808

  4. Or emailed to: fraud&abuse@hmsa.com
CURRENT AS OF 08/03/2026