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 healthcare 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 healthcare 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 healthcare 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 is payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.
Fraud, waste and abuse training
Contracted healthcare providers and third parties supporting Humana’s Medicare and/or Medicaid products must train their employees and those supporting them to meet certain contractual obligations to Humana.
- developing training on combating fraud, waste and abuse or using another training to meet that educational requirement.
- tracking the training
Note: To assist your organization, Humana material from the Standards of Conduct and Compliance Policy documents referenced further down this page may be integrated within the fraud, waste and abuse training or used as supplemental material.
*CMS designates these as first tier, downstream or related entities (FDRs).
Additional compliance program requirements for FDRs
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.
Standards of conduct
Here we have posted our “Ethics Every Day for Contracted Healthcare Providers and Third Parties”, which is closely aligned with Humana's standards of conduct for its employees. We invite contracted healthcare providers and third parties to review this information as soon as possible.
Ethics Every Day for Contracted Healthcare Providers and Third Parties
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 healthcare providers and third parties 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 Healthcare Providers and Third Parties
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 improve the healthcare system and reduce costs for our members, customers and third parties.
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, opens new window
You have the option for your report to remain anonymous. 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.
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.
SIU tools and resources
Humana's SIU utilizes software tools that help find and prevent healthcare 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:
- Medical and Pharmacy Coverage Policies, opens new window
- Medicare Coverage Database – Centers for Medicare & Medicaid Services National Coverage Determination (NCD) and Local Coverage Determination (LCD), opens new window
- American Medical Association (AMA) Current Procedural Terminology (CPT®), International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) and Healthcare Common Procedure Coding System (HCPCS) coding references
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, dental or pharmacy records. We do this to validate that the records support the services billed. It's important that the healthcare 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 provider's name
- Alteration of records to get services covered