Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)
Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Abuse includes any action(s) that may, directly or indirectly, result in one or more of the following:
Abuse involves payment for items or services when there is no legal entitlement to that payment and the entity supporting Humana (e.g. health care provider or supplier) has not knowingly and/or intentionally misrepresented facts to obtain payment.
Abuse cannot always be easily identified, because what is “abuse” versus “fraud” depends on specific facts and circumstances, intent, and prior knowledge, and available evidence, among other factors.
Humana has adopted training content published by the Centers for Medicare & Medicaid Services (CMS) that addresses this subject matter. For purposes of the relationships that contracted health care providers and business partners* have with Humana, this training, including all references and requirements related to Medicare Part C and Part D, is applicable to all Humana lines of business. This includes Commercial, Medicare Part C and Part D, dual Medicare-Medicaid, and Medicaid.
Contracted health care providers and business partners supporting Humana’s Medicare and/or Medicaid products, must use CMS content to train their employees and the entities supporting them to meet certain contractual obligations to Humana.
* CMS designates these as first tier, downstream, or related entities (FDRs).
Accessing the CMS Training Material
Additional compliance program requirements for FDRs supporting Humana’s Medicare and/or Medicaid products are outlined in, but not limited to the documents listed in subsequent sections of this page.
Here we have posted our Ethics Every Day for Contracted Health Care Providers and Business Partners, which is closely aligned with Humana's standards of conduct for its employees. We invite contracted health care providers and business partners to review this information as soon as possible.
Ethics Every Day for Contracted Health Care Providers and Business Partners
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 its contracted health care providers and business partners to uphold a similar commitment to ethical conduct and assure that they, their employees, and downstream entities who support Humana comply with the guiding principles outlined in this policy.
Compliance Policy for Contracted Health Care Providers and Business Partners
If you suspect fraud, waste, or abuse in the healthcare system, you must 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 business partners.
To report suspected fraud, waste, or abuse, you can contact Humana in one of these ways:
You may remain anonymous if you prefer. All information received or discovered by the Special Investigations Unit (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.
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:
Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:
Some of the most common coding and billing issues are: