Special Investigations Unit

 

In order to be good stewards of Medicare funds, as well as keep costs low for our members, MediGold is committed to program integrity efforts by early identification, correction and prevention of health care fraud, waste and abuse (FWA) through its  Special Investigations Unit (SIU).

MediGold's SIU utilizes various methods in its efforts to address FWA including, but not limited to software and data analytics tools. These resources assist in detecting claim aberrancies, outlier behavior, over/under-utilization and potentially inappropriate billing practices.

Procedures are in place to promptly address non-compliance and potential FWA issues, as well as reporting identified issues to appropriate authorities. Investigative and corrective steps by the SIU may include things such as interview, medical record reviews, verbal/written provider education, written and document corrective action plans, recovery of funds, appropriate federal and state law enforcement/MEDIC referrals or other legal action.

Preventing and Identifying Medicare Fraud, Waste and Abuse

What is fraud, waste and abuse?

Fraud

  • Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist
  • Knowingly soliciting, paying and/or accepting payment to induce or reward referrals for items or services reimbursed by federal health care programs.
  • Making prohibited referrals for certain designated health services.
  • Requires intentional deception or misrepresentations made by someone with the knowledge that the deceptions could result in unauthorized benefits or payments that they would not have been otherwise entitled to. This could include a false statement, misrepresentation or a deliberate omission of facts or information that is critical in making a determination of whether a benefit is payable.

Waste

Typically defined as overutilization or misuse of services or practices which, either directly or indirectly, result in unnecessary costs.

Abuse

Practices that are inconsistent with sound fiscal, business or medical practices and result in unnecessary costs. These could include services which are not medically necessary or fail to meet professionally recognized standards of care, or result in improper payments. In addition, abuse can involve charging excessively for services or supplies or up-coding for services provided. In such abuse situations, a knowing or intentional misrepresentation of statement or fact is not necessary to obtain the payment.

Examples of Provider, Pharmacy or Vendor FWA

  • Prescribing medications or supplies which are not medically necessary.
  • Ordering medically unnecessary testing.
  • Billing for services not rendered.
  • Employing excluded individuals.
  • Engaging in kickback arrangements.
  • Misrepresenting services provided in order to receive higher reimbursement.
  • Dispensing drugs purchased outside the U.S.
  • Dispensing generic drugs but billing for brand.
  • Intentionally dispensing less than the prescribed quantity (shorting).
  • Billing for prescriptions not received by the member or not filled.

How to Report FWA

 

If you suspect someone of committing FWA against you or MediGold, report any suspicious activity in one of these ways:

If you prefer, you may report FWA anonymously:

  • Call our parent company's (Trinity Health) anonymous Integrity Hotline at 866-477-4661. Indicate you want to report a FWA matter concerning MediGold.
  • Report FWA via U.S. Mail:
    MediGold Special Investigations Unit
    6150 East Broad St., EE320
    Columbus, OH 43213

Updated 01/2018