I. Definition
The Health Insurance Portability and Accountability Act (HIPAA) makes it a federal offence to submit fraudulent claims to any healthcare plan. Generally, fraud involves the intentional misrepresentation or concealment of material facts related to claims, treatment, and/or medical records and other relevant factors and circumstances. Practices that are considered fraudulent by HMSA include, but are not limited to:
- Double billing for services provided;
- Providing and/or billing for services that are not medically necessary;
- Billing for services that are not rendered;
- Upcoding the complexity or level of a service beyond what was actually rendered;
- Unbundling or split billing, for services that can be accurately described by a single CPT code;
- Falsifying medical records to receive higher reimbursements and/or inaccurately documenting services rendered;
- Using another person's HMSA member card to obtain services, with or without the knowledge of the cardholder; and
- Routinely waiving copayments or overcharging patients’ copayment amounts.
II. HMSA’s Investigation of Potential Fraud
HMSA’s Special Investigations Unit is dedicated to identifying, investigating and preventing fraud and abuse under all lines of HMSA business. HMSA identifies potential fraud through a variety of means. These include, but are not limited to:
- Complaints from members and providers;
- Information provided by law enforcement; and
- Cases proactively developed through claims data analysis.
In cases involving your billings, HMSA may:
- Request and audit a provider’s medical records;
- Review paid claims;
- Interview patients or witnesses; and
- Follow-up to determine whether 1) billings for your services were appropriate and 2) the provider was correctly paid for the services.
Before closing a case, audit findings will be furnished to you and you will have the opportunity to comment on the findings.
The majority of cases reviewed by HMSA do not result in a finding of fraud. In most cases, HMSA findings indicate that overpayments to providers are due to circumstances such as misunderstanding of coding guidance or billing errors.
HMSA will recover any overpayments that are identified as the result of fraud, improper billings, or payments. (See Benefit Overpayment and Benefit Overpayment – Senior Plans for more information about the method of recovering overpayments.)
III. When Fraud is Identified
When a case of fraud is identified, HMSA will terminate its contract with you.
Cases of fraud will also be referred to the appropriate state or federal law enforcement agencies (e.g., Federal Bureau of Investigation, Office of the Inspector General, Medicaid Investigations Division and the State of Hawaii – Narcotic Enforcement Division) for possible criminal investigation.
IV. Provider Steps to Prevent Fraud
There are a number of things you can do to prevent fraud and protect yourself from being the subject of a fraud investigation. These include the following:
- Monitoring your billings to confirm that staff members are properly billing HMSA and government plans for the services provided.
- Check patient identification (e.g., driver’s license, state ID card), for patients unknown to your practice, against the HMSA member card presented, prior to rendering service.
- Keep medical records that are legible, complete and accurately document the services provided.
- Provide ongoing education to staff regarding proper documentation and billing practices.
HMSA encourages providers to be vigilant in your efforts to prevent fraud. When fraud is committed, everyone loses.