What are Fraud, Waste, and Abuse?
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:
- Unnecessary costs to the health care system, including the Medicare and Medicaid programs
- Improper payment for services
- Payment for services that fail to meet professionally recognized standards of care
- Services that are medically unnecessary
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.
Fraud, Waste, and Abuse and General Compliance Training
Humana has adopted a training document published by the Centers for Medicare & Medicaid Services (CMS) that includes 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.
Humana suggests contracted health care providers and business partners use this document to simplify their training process, although they may use another training that is materially similar.
* CMS designates them as first tier, downstream, and related entities (FDRs).
Accessing the CMS Training File
1) Navigate to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
2) Scroll to the “Downloads” section
3) Click on “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training”
4) Select “Open” or “Save”; the training is available in both PDF and PowerPoint formats
Puerto Rico - Spanish (3.5MB)
Ethics Every Day
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
Ethics Every Day for Contracted Health Care Providers and Business Partners - English (1.9 Mb)
Ethics Every Day for Contracted Health Care Providers and Business Partners - Spanish (6.4 Mb)
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
Compliance Policy for Contracted Health Care Providers and Business Partners - English (765 Kb)
Compliance Policy for Contracted Health Care Providers and Business Partners - Spanish (3.4 Mb)
How to Report Fraud, Waste, and Abuse
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:
- Phone: English 1-800-614-4126
- Fax: 1-920-339-3613
- E-mail: firstname.lastname@example.org
- 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 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.
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. 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 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