Fraud is defined as “any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or him/her or some other person in a managed care setting.” It includes any act that constitutes fraud under applicable federal or state law. Fraud may be found under the following conditions (the following list is intended as an example and not as a limitation):
- When a provider submits a bill for a service that was not provided; or
- When a provider bills for a time period greater than the time actually spent with the client; or
- When a provider bills for the provision of a service that did not meet the service definitions, performance specifications, state or federal regulations, or accreditation standards customarily recognized in behavioral health care; or
- Inappropriate or frequent referrals that may constitute a conflict of interest; or
- Authorizations for services to providers who may have personal or other financial relationships with care managers; or
- Other related claims or care management issues that may involve intentional deception or misrepresentation as referenced above.
Waste is defined by the OIG as the intentional or unintentional, thoughtless or careless expenditure, consumption mismanagement, use, or squandering of government resources to the detriment or potential detriment of government programs. Waste also includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, or controls.
Abuse is defined as “any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to NMHC, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations for health care in a managed care setting.” It also includes recipient practices that result in unnecessary cost to NMHC.
Examples: Altering claims, double billing, billing for services not provided, over-utilization; kickbacks, using fraudulent credentials and pharmacies billing for brand when generic drugs are dispensed.
Federal and State Statutes and Regulations Applicable to NMHC Providers:
- The New Mexico Insurance Fraud Act (59A-16C NMSA)
- The False Claims Act (31 U.S.C. 3729-3733)
- The Anti-Kickback Statute (42 U.S.C. 1320a-7b(b) and 42 C.F.R. 1001.952)
- The Physician Self-Referral Law (42 U.S.C. 1395nn and 42 C.F.R. 411.350)
- The Exclusion Authorities (42 U.S.C. 1320a-7; 1320c-5 and 42 C.F.R. 1001 and 1002)
- The Civil Monetary Penalties Law (42 U.S.C. 1320a – 7a and 42 C.F.R. 1003)
- The Health Care Fraud Statute (18 U.S.C. 1347 and 1349)
- The Patient Protection and Affordable Care Act
Reporting Potential Fraud, Waste, and Abuse and Other Suspicious Activity
Reports are confidential. When reporting suspicious behavior, you may remain anonymous. To report:
- Contact our Fraud, Waste, and Abuse hotline: 1-855-882-3903, or (505) 492-2058, extension 156
- Download our Fraud, Waste, and Abuse Report form and fax it to 1-866-231-1344
- Write to us:
New Mexico Health Connections
P.O. Box 36719
Albuquerque, NM 87176