Fraud, Waste and Abuse

In order to be good stewards of Medicare funds, as well as keep costs low for our members, Mount Carmel MediGold Health Plan is committed to program integrity efforts by early identification, correction and prevention of health care fraud, waste and abuse through our Special Investigations Unit (SIU).

The SIU utilizes various methods in its efforts to address FWA including, but not limited to software and data analytics tools. These resources assist in detecting claim aberrancies, outlier behavior, over/under-utilization and potentially inappropriate billing practices.

Procedures are in place to promptly address non-compliance and potential fraud, waste, and abuse issues, as well as reporting identified issues to appropriate authorities. Investigative and corrective steps by the SIU may include things such as interview, medical record reviews, verbal/written provider education, written and document corrective action plans, recovery of funds, appropriate federal and state law enforcement/MEDIC referrals or other legal action.

What is fraud, waste, and abuse?

Fraud

Medicare fraud typically includes any of the following:

• Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist.
• Knowingly soliciting, paying and/or accepting payment to induce or reward referrals for items or services reimbursed by federal health care programs.
• Making prohibited referrals for certain designated health services.

Waste

Defined as overutilization or misuse of services or practices which, either directly or indirectly, result in unnecessary costs.

Abuse

Defined as practices that are inconsistent with sound fiscal, business or medical practices and result in unnecessary costs. These could include services which are not medically necessary or fail to meet professionally recognized standards of care, or result in improper payments. In addition, abuse can involve charging excessively for services or supplies or up-coding for services provided. In such abuse situations, a knowing or intentional misrepresentation of statement or fact is not necessary to obtain the payment.

How to report fraud, waste, and abuse

If you suspect someone of committing fraud, waste, or abuse against you or Mount Carmel MediGold Health Plan, please report it to our Special Investigations Unit in one of these ways.

Online: SIU Form

Phone: 614-546-4392
Email: SIU.MediGold@mchs.com
Fax: 614-234-9074

Mail:

Mount Carmel MediGold Health Plan Special Investigations Unit
3100 Easton Square Place, Suite 300
Columbus, OH 43219

If you prefer, you may report FWA anonymously through our parent company's (Trinity Health) anonymous Integrity Hotline at 866-477-4661. Indicate you want to report a FWA matter concerning Mount Carmel MediGold.