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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)

Please review KelseyCare Advantage's Compliance, Fraud, Waste, and Abuse Training.
MEDICARE FRAUD
Member Education

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.
 
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 farud, 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
  • 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 prescripts 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 policy holder 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.
 
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.

Fraud, Waste, and Abuse Hotline:  713-442-9595
MedicareFraudHotline@KelseyCareAdvantage.com

In writing:

KelseyCare Advantage
Attn:  Compliance
11511 Shadow Creek Parkway
Pearland, Texas 77584

All communications are confidential and may be anonymous.

www.insurancefraud.org
www.stopmedicarefraud.gov

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.

Code of Conduct and Business Ethics

Our Compliance Policies & Procedures, Standards of Conduct, and Anti-Fraud Plan are available here:

Compliance Attestations (Required)

KCA Employees: Please click on the following link to complete the required attestations
https://www.surveymonkey.com/r/7GNS2CQ

KCA Delegates: Please click on the following link to complete the required attestations
https://www.surveymonkey.com/s/JW3JBYB

If you have any questions please contact KCA Compliance Department at 713-442-9595 or MedicareFraudHotline@KelseyCareAdvantage.com.

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