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Compliance and Fraud
Below you will find information on KelseyCare Advantage’s (KCA) Compliance and Fraud Waste and Abuse Programs.
- Medicare Compliance, Fraud, Waste, and Abuse Training (Employee, Contractor, and Delegates)
- Medicare Fraud
- Our Commitment to Address Fraud, Waste, and Abuse
- Examples of Healthcare Fraud
- Protect Yourself Against Fraud
- Help Fight Fraud
- KelseyCare Advantage's Code of Conduct, Policies and Procedures
The Scope of Fraud, Waste, and Abuse on our Healthcare System
The National Healthcare Anti-Fraud Association (NHCAA) cites an average of 3% (at the low end) and 10% (at the high end) of healthcare spending is lost due to fraud. That’s between $67 billion and $230 billion lost each year to fraud, waste, or abuse. That estimates to between $184 million and $630 million loss per day, and this number is expected to increase every year as healthcare costs rise. Healthcare fraud is believed to be the second largest white-collar crime in the United States. It is often mistaken for a victimless crime, but it affects everyone. Fraud causes insurance premiums to rise, and victims may be put through unnecessary or unsafe procedures. Victims of identity theft may find their insurance information used to submit false claims. This is a staggering cost, and we are committed to battling these unnecessary expenditures every step of the way.
KelseyCare Advantage is committed to fighting healthcare fraud, waste, and abuse.
We have a dedicated staff whose mission is to protect our employees, members, providers, first tier, downstream, and related entities, and the Medicare Trust Fund by administering an effective plan to prevent and detect fraud, waste, and abuse.
Our team works diligently to investigate all allegations, correct known offenses, recover lost funds, and partner with federal and state agencies to prosecute violators to the fullest extent of the law.
- A healthcare provider bills for medical services, supplies, or items that were not provided.
- A healthcare provider bills for more expensive services or procedures than what was actually provided or performed.
- A healthcare provider performs medically unnecessary services to obtain the insurance payment.
- A healthcare provider misrepresents a non-covered service as medically necessary to obtain the insurance payment.
- A healthcare provider or pharmacy charges a beneficiary a price over the copay amount.
- A healthcare provider or pharmacy waves the patient copay amount and overbills the insurance plan to recoup the cost.
- A pharmacy bills for prescriptions that were not dispensed.
- A pharmacy dispensed a generic drug but billed for a brand name drug.
- Prescription drug “shorting” by pharmacy (i.e., billing for 60 tablets, but dispensing 30).
- A pharmacy adding unauthorized refills to prescriptions.
- Drug diversion.
- A pharmacy, beneficiary, or policyholder forges or alters a prescription.
- A beneficiary or policyholder misrepresents their personal information such as identity, eligibility, or medical condition in order to illegally receive a benefit.
- Someone steals or purchases a beneficiary’s or policyholder’s personal information to submit false or phantom claims to obtain the insurance benefit.
- A beneficiary or policyholder allows a third party to use their benefit information to obtain medication and/or medical services.
- A third party pretends to represent Medicare, the Social Security Administration, or an insurance plan for the purpose of obtaining personal and/or financial information.
- Treat your Medicare card, Social Security card, and insurance ID card like you would your credit card. It could be very costly if they fell into the wrong hands.
- Do not give out personal information over the phone or through mail unless you have initiated the contact.
- Be cautious of providers who offer “free” testing or screening but require your Medicare and/or insurance card first. Thieves use this scam to get personal information then use it to commit fraud or sell it.
- Avoid utilizing a healthcare provider or pharmacy who tells you that the item or services is not usually covered, but they know how to bill Medicare to get it paid.
- Review your Explanation of Benefits (EOB) promptly. Look for:
Charges for a service, drug, equipment, and/or supplies you did not get.
Billing for the same service, drug equipment, and/or supplies twice.
- Services that were not ordered by the doctor.
- Report fraud. Contact the Special Investigation Unit if you suspect fraud, waste, or abuse.
If you suspect someone of committing insurance fraud against KelseyCare Advantage or think you may be a victim, please report the suspicious activity by calling, mailing or e-mailing us.
11511 Shadow Creek Parkway
Pearland, Texas 77584
All communications are confidential and may be anonymous.
The Centers for Medicare and Medicaid Services requires that all health plan employee first-tier downstream and related entities review the contract holder Standards of Conduct, Policies & Procedures, and Complete Compliance and FWA training upon the first 90 days of hire and annual thereafter.
Please review KCA’s policies below.
Our Compliance Policies & Procedures, Standards of Conduct, and Anti-Fraud Plan are available here:
- Policy 1: Compliance Committee
- Policy 2: Compliance Communication
- Policy 3: Conflict of Interest
- Policy 4: Training and Education
- Policy 5: Reporting Misconduct
- Policy 6: Compliance Hotline
- Policy 7: Internal Investigations
- Policy 8: Monitoring and Auditing
- Policy 9: Background Checking OIG Exclusion
Compliance Attestations (Required)
KCA Employees: Please click here to complete the required attestations
KCA Delegates: Please click here to complete the required attestations