Fraud, Waste, & Abuse


Fraud, Waste & Abuse Prevention

At Health Pointe of New York, we have a zero-tolerance policy on Fraud, Waste and Abuse (FWA), and everyone is responsible to make a difference. The mission of the Plan’s Special Investigations Unit (SIU) is to protect the overall integrity of the healthcare system, as well as to protect our members, providers, business partners and stakeholders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential FWA.

As part of the overall Compliance and FWA program, the SIU maintains written policies and procedures and adheres to the Corporate Code of Conduct which articulates the organization’s commitment to comply with all applicable Federal and State standards, including measures to detect, correct, and prevent FWA. Health Pointe recognizes the importance of building the foundation of the Company’s FWA program around prevention versus post-payment recovery or a ‘pay and chase’ philosophy. Health Pointe places great emphasis on leveraging real time data, technology and staff intervention at an earlier stage in the entire health care cycle to reduce vulnerability, lack of transparency and impact to FWA. This serves as the cornerstone of our ability to protect our beneficiaries and the overall integrity of the health care system as a whole.

Definitions and Examples

Fraud

A false representation of a matter of fact – whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed – that deceives and is intended to deceive another so that the individual will act upon his or her legal injury.

Abuse

Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid or Medicare program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid or Medicare program.

Waste

An attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, but the outcome of a billing error caused unnecessary costs to the involved companies. Waste includes overutilization of services not caused by criminally negligent actions. Waste also involves the misuse of resources.

Services Not Rendered

Billing for goods and/or services that were never delivered or provided.

Not Medically Necessary

Performing inappropriate or unnecessary medical procedures in order to increase payment.

Unbundling

Using multiple billing codes instead of one billing code for a drug panel test in order to increase payment.

Up-coding

Billing for a higher level of service than was actually provided.

Misrepresentation

Forging a physician’s signature to obtain pharmaceutical goods.

Double Billing

Charging more than once for the same goods or services.

Underutilization

Not providing adequate medical care to increase profits.

Enrollment Fraud

Enrolling a beneficiary into a health plan without that person’s knowledge.

Theft of Services

Utilizing someone else’s insurance card to receive services; either through stealing the card or having it provided by the true card holder.

Overpayment

Overpayment includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.

Reporting Health Care Fraud, Waste & Abuse

If you have a reason to believe Fraud, Waste or Abuse (FWA) may have been committed, please contact us immediately and together we can make a difference.

  • Call the Confidential Compliance and Fraud, Waste & Abuse Hotline at 844-269-3442 Ext. 106590.
  • Submit the Healthcare Fraud, Waste & Abuse Referral Form

Email the SIU at compliancereporting@ilshealth.com

  • Mail your concern to the following address: Special Investigations Unit, Health Pointe of New York, 810 7thAve, Suite 801 New York, NY 10019

If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Inspector General’s Fraud Rewards Program. You can call the Inspector General’s office at 1-800 367-4448. You can talk to the Attorney General’s office about keeping your identity confidential and protected.

New York Department of Financial Services, Insurance Fraud Bureau: 888 372-8369

Department of Health and Human services, OIG Medicare Fraud Hotline: 1-800-HHS-TIPS

Whistleblower Protection: The Civil False Claims Act (31U.S. Code § 3729-3731) provides for protection for employees from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in terms and conditions of employment because of lawful acts done by the employee, contractor, agent or associated others in furtherance of an action under this Act may bring an action in the appropriate district court of the United States for relief, including reinstatement, back pay, or other compensation.

HEALTHCARE FRAUD, WASTE & ABUSE REFERRAL FORM


You may choose not to include your name, and your report may remain anonymous and confidential.

INSTRUCTIONS: Please provide as much information as possible regarding the allegation. After coompleting this form, please click “Submit” and the information will be sent securely to Health Pointe Direct Complete Plan Special Investigations Unit (SIU). Any additional information or attachments can be e-mailed to compliancereporting@ilshealth.com

If you have questions on how to complete this form or would like to report your allegations verbally, please contact the Fraud Waste and Abuse Hotline at 1-800-HHS-TIPS

Please provide us with your contact information (Optional):

Contact Us:

Toll-Free: 1.844.269.3442 

TTY: 711

Mailing Address:

Health Pointe of New York

810 Seventh Avenue – Suite 801

New York, New York 10019

Please contact our Member Services number at 1-844-269-3442 for additional information. (TTY users should call 711.) From October 1 to March 31, we are open 7 days a week, from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we are open Monday through Friday, from 8 a.m. to 8 p.m. EST.

We do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, gender identity, age or disability in our health programs and activities.

ATENCION: Si habla español, tiene a su diposicion servicios gratuitos de assistencia linguistica. Llame a 1.844.269.3442 / TTY: 711

Health Pointe Direct Complete Plan (HMO SNP) is a Health Plan with a Medicare Contract. Enrollment in Health Pointe HMO SNP depends on contract renewal.

CMS Material ID: H1722_HPweb2019 | Last updated 10/01/2019

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