Fraud, Waste & Abuse
Fraud, Waste, Abuse & Overpayments
Magellan Behavioral Care of Iowa, Inc. (Magellan) is dedicated to conducting business in an ethical and legal manner. Magellan is committed to preventing, detecting and reporting fraud, waste, abuse, and overpayments. If you suspect fraud, you are obligated to report it. Magellan aggressively pursues allegations of health care fraud, waste, abuse, and overpayments. There is also information about fraud, waste, and abuse in the Member Handbook.
Abuse - Abuse refers to overused or unneeded services. Abuse also includes member actions that result in unnecessary cost to the Iowa Medicaid Program.
Fraud - It is an intentional deception or misrepresentation or a false action that is used to gain something of value.
Waste - Excessive or improper use of services.
Overpayments - Any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, waste, or mistake.
Examples of fraud, waste, abuse, and overpayments include:
- Billing for health care services that are not needed;
- Billing twice for the same service;
- Using a billing code to get extra payments;
- Using another person's identity to get Medicaid services;
- Making false documents by changing:
- The date of service for a claim.
- Medical records.
- Referral forms.
- Paying or taking a bribe;Billing for services or procedures that have not been performed or have been performed by others;
- Submitting false or misleading information about services performed;
- Misrepresenting the services performed (e.g., up-coding to increase reimbursement);
- Retaining and failing to refund and report overpayments (e.g., if your claim was overpaid, you are required to report and refund the overpayment, and unpaid overpayments also are grounds for program exclusion)
- Providing or ordering medically unnecessary services and tests based on financial gain;
- An individual provider billing multiple codes on the same day where the procedure being billed is a component of another code billed on the same day (e.g., a psychiatrist billing individual therapy and pharmacological management on the same day for the same patient)
- Submitting claims for services ordered by a provider that has been excluded from participating in federally and/or state-funded health care programs; and
- Lying about credentials, such as degree and licensure information.
Reporting Medicaid Fraud, Waste, Abuse, & Overpayments
If you think an individual, company, or provider is committing fraud, waste, abuse or retaining overpayments, please report it. You can report it to Magellan or directly to State regulatory agency.
Report Fraud, Waste, Abuse, & Overpayments to Magellan
You can report fraud, waste, abuse, and overpayments to Magellan’s Special Investigations Unit (SIU).
o Magellan's Special Investigations Unit hotline: 1-800-755-0850
o Magellan's Special Investigations Unit e-mail: SIU@MagellanHealth.com
You can also report fraud, waste, abuse, and overpayments through the Magellan Corporate Compliance hotline which is available 24 hours a day, seven days a week. It is handled by an outside company. Callers do not have to give their names. All calls will be investigated and will remain confidential.
o Corporate Compliance Hotline: (800) 915-2108
o Compliance Unit Email: Compliance@magellanhealth.com
Report Fraud, Waste, Abuse, & Overpayments to State Agencies
You can report suspected cases of fraud, waste, abuse, and overpayments directly to the agencies listed below:
a) Reports can be made to theIowa Medicaid Enterprise @ 1-800-831-1394, or to the IME Program Integrity Office:
Report Suspected Medicaid Fraud
Iowa Department of Human Services
Iowa Medicaid Enterprise
Program Integrity Unit
Toll Free - (877) 446-3787
Des Moines area - (515) 256-4615
The Hot Line is staffed from 8:00 a.m. - 5:00 p.m. Monday-Friday.
b) Reports can also be made to the Iowa Medicaid Fraud Control Unit:
Department of Inspections and Appeals
Medicaid Fraud Control Unit
c) Insurance Fraud Bureau of the Iowa Insurance Division
* Consumers and General Public:
* You can call the Insurance Fraud Bureau at 1-877-955-1212 to report fraud.
* You can also use the Online Fraud Reporting System for Consumers:
You are welcome to make a referral to the Insurance Fraud Bureau by using the public referral form, or reporting online. To report online, including anonymous reports, go to the National Association of Insurance Commissioner's website at http://www.iid.state.ia.us/file_a_complaint/online_form
* If you prefer to download a reporting form to send it to the Insurance Fraud Bureau, use the Insurance Fraud Complaint Form (for Public use) which is available at http://www.iid.state.ia.us/insurance_fraud
Mail or Fax Form to:
Insurance Fraud Bureau
Iowa Insurance Division
601 Locust, 4th Floor
Des Moines, Iowa 50309-3738
d) U.S. Department of Health & Human Services Office of Inspector General:
Contact the Office of the Inspector General at 1-800-447-8477 or by e-mail to HHSTips@oig.hhs.gov or by mail to the address below.
Office of Inspector General
U.S. Department of Health & Human Services
ATTN: OIG HOTLINE OPERATIONS
PO Box 23489
Washington, DC 20026