Fraud, Waste and Abuse Prevention Training Guide
Humana is providing this Fraud, Waste and Abuse Prevention Training Guide as a resource for meeting the Centers for Medicare & Medicaid Services (CMS) requirement that contracted entities provide fraud, waste and abuse prevention training to their employees who administer or deliver Medicare benefits or services.
- Fraud, Waste and Abuse Prevention Training Guide for Health Care Providers, Vendors and Related Entities
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- English | Spanish
Principles of Business Ethics
We have posted our Principles of Business Ethics (PBE) for Health Care Providers, Vendors and Related Entities, Humana's code of conduct. We invite providers to review this information as soon as possible.
- Principles of Business Ethics for Health Care Providers, Vendors and Related Entities
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This policy communicates Humana's strong and explicit organizational commitment to conducting business ethically, with integrity and in compliance with applicable laws, regulations and requirements. Humana requires of its health care providers, vendors and related entities a similar commitment to ethical conduct and assurance that they and their employees, representatives and subcontractors who work on Humana accounts comply with the guiding principles outlined within this policy.
- Compliance Policy for Health Care Providers, Vendors and Related Entities
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Report Fraud, Waste & Abuse
If you suspect fraud, waste, or abuse in the healthcare system, you can report it to Humana and we'll investigate. Your actions may help to improve the healthcare system and reduce costs for our members, customers, and the people we do business with.
What is Fraud, Waste, and Abuse?
Fraud is generally defined as making a false claim in an effort to receive payment. For example, fraud in the healthcare industry can involve:
- Billing for medical services that weren't ordered or provided
- Billing for durable medical equipment items that weren't ordered or provided
- Providing services or items a person doesn't need based on his or her medical history
- "Doctor shopping" – when a patient who may or may not have a legitimate physical ailment goes from doctor to doctor to obtain multiple prescriptions for narcotic painkillers
To protect yourself from fraud, thoroughly review your Explanation of Benefits (EOB) after you receive healthcare services. If you see something that doesn't look right, you should report the situation right away.
How to Report Fraud, Waste, and Abuse
To report suspected fraud, waste, or abuse, you can contact Humana in one of these ways:
- Phone: English 1-800-614-4126
- Fax: 1-920-339-3613
- Mail: Humana, Special Investigation Unit, 1100 Employers Blvd., Green Bay, WI 54344
- Ethics Help Line: 1-877-5-THE-KEY (1-877-584-3539)
- Ethics Help Line Reporting website: www.ethicshelpline.com
You may remain anonymous if you prefer. All information received or discovered by the SIU will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, Humana corporate law department, market medical directors or Humana senior management).
Another option is to submit the Special Investigations Referral Form online, by filling out the form using the link below.
If you are a Medical, Dental or Pharmacy provider and have a concern previously reported to SIU, you can follow up by filling out the Request to Contact SIU Form.
Special Investigation Unit (SIU) Tools and Resources
Humana's Special Investigation Unit (SIU) utilizes software tools that help find and prevent health care fraud. This fraud detection software also allows us to review our claims for possible fraud before payment.
SIU references the following resources to support its investigations:
What We Do
Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:
- Contact with relevant parties to gather information. This may include contacting members to get a better understanding of the situation. For example, we may contact a member to ask about a visit with his or her physician. We may ask the member to describe the services provided, who provided the care, how long the member was at the office, etc.
- Requests for medical or dental records. We do this to validate that the records support the medical or dental services billed and that the correct coding was used. It's important that the health care provider submits complete records as requested. We rely on this information to make a fair and appropriate decision.
- Notification of suspected fraud and abuse to law enforcement and CMS, if applicable, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare part C (medical) and part D (prescriptions) and any other applicable state and/or federal agencies.
Most Common Coding and Billing Issues
Some of the most common coding and billing issues we see are:
- Billing for services not rendered
- Billing for services at a frequency that indicates the provider is an outlier as compared with their peers.
- Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
- Billing for services that are actually performed by another provider
- Modifier misuse, for example modifiers 25 and 59
- Billing for more units than rendered
- Lack of documentation in the records to support the services billed
- Services performed by an unlicensed provider but billed under a licensed providers name
- Alteration of records to get services covered