KelseyCare Advantage’s (KCA) Compliance and Fraud Waste and Abuse Programs
- 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
One of the current schemes in place is members receiving “robo calls.” Members get an unsolicited phone call that have been “spoofed” to appear to be coming from Medicare. The call will come in and the caller ID will indicate it is coming from 1-800-MEDICARE but in all actuality the call is coming from overseas.
The Scope of Fraud, Waste, and Abuse on our Healthcare System
The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300 billion.
Our Commitment to Address Fraud, Waste, and Abuse
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.
Examples of Healthcare Fraud
- Billing for services that were never rendered—by using patient information, sometimes obtained through identity theft to fabricate entire claims or by padding otherwise legitimate claims with charges for procedures or services that did not take place.
- Billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding”—i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying “inflation” of the patient’s diagnosis code to a more serious condition consistent with the false procedure code).
- Performing medically unnecessary services solely for the purpose of generating insurance payments—this is seen very often in diagnostic-testing schemes such as nerve-conduction and genetic testing.
- Misrepresenting non-covered treatments, as medically necessary covered treatments for purposes of obtaining insurance payments—this is widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as “nose jobs” are billed to patients’ insurers as deviated-septum repairs.
- Falsifying a patient’s diagnosis and medical record to justify tests, surgeries or other procedures that aren’t medically necessary.
- Unbundling—billing for each step of a procedure as if they are separate procedures.
- Billing a patient more than the required co-pay amount for services that were prepaid or paid-in-full by the benefit plan under the terms of a managed care contract.
- Accepting kickbacks for patient referrals.
- Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to a true “financial hardship”).
Protect Yourself Against Fraud
- 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.
Help Fight Fraud
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.
Link: Online Reporting Form
11511 Shadow Creek Parkway
Pearland, Texas 77584
All communications are confidential and may be anonymous.
KelseyCare Advantage’s Code of Conduct, Policies, and Procedures
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:
- Medicare Advantage and Part D Fraud, Waste, and Abuse
- Compliance Communication Policy
- Training and Education Policy
- Reporting Misconduct / Compliance Hotline Policy
- Monitoring and Auditing Policy
- Prompt Response to Compliance Issues Policy