Fraud, waste and abuse

Fraud, Waste and Abuse Policy

WellSense Health Plan is committed to the stewardship of the State and Federal dollars that fund our program. As part of this commitment, we must ensure that healthcare services provided to eligible members are done so by providers entitled to participate in federal programs, are medically necessary, meet certain quality requirements, are provided in a cost effective manner, are billed appropriately, and are paid according to contract terms and WellSense policies. To that end, WellSense, in the course of normal operations, works to prevent fraud, waste and abuse (FWA) and to detect and correct any instances of FWA, whether member, provider, employee, or vendor/contractor-focused. See our full Fraud, Waste and Abuse policy.

Why is fraud, waste and abuse an issue?

Studies by a variety of federal agencies and private organizations estimated the cost of fraud, waste and abuse in the healthcare industry, including federal programs, to be in the tens of billions of dollars a year. The resulting increase in the cost of healthcare affects all of us---all providers, health care recipients, and health plans, not only the small percentage of providers who engage in it.

What are fraud, waste and abuse?

Fraud is generally defined as intentionally making, or attempting to make a false claim, representation or promise in an effort to receive payment or property to which one is not entitled.

Abuse refers to actions or inactions by that are inconsistent with sound fiscal, business or medical practices, and that result in unnecessary cost to BMCHP.

Waste generally means over-use of services or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.

Examples of fraud, waste and abuse in the healthcare industry include, but are not limited to:

• Providing services that are not medically necessary, given a member’s medical history;
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary;
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining payment;
• Rendering services that fail to meet professionally recognized standards;
• Failing to accurately document services provided;
• Failing to review the results of ordered tests;
• Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding";
• Billing each step of a procedure as if it were a separate procedure, commonly known as “unbundling”;
• Billing for services at a frequency greater than a provider’s peer group;
• Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place;
• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of the member’s health plan;
• Accepting kickbacks for patient referrals; and
• Waiving patient co-pays or deductibles.

How is fraud, waste and abuse identified?

Our Special Investigation Unit (SIU) receives referrals regarding suspicious behavior from multiple internal and external sources, including an anonymous hotline. In addition, SIU staff utilize a variety of software tools to both help find and prevent health care fraud prior to and after claim payment. These tools employ rules that are consistent with provider contracts, WellSense clinical and reimbursement policies, and Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD) coding guidelines.

What do we do when fraud, waste or abuse is suspected?

Upon receipt of referrals and/or identification of outliers, the SIU initiates an investigation, which may include:

• Interviewing internal and external stakeholders, including provider(s), member(s), vendor(s), and/or others, to gather information pertinent to the case.
• Requesting and reviewing medical or other healthcare records for the purpose of verifying that billed services were provided and were coded correctly.
• Consulting state agencies, up to and including the state Medicaid office, Medicaid Fraud Division and/or Attorney General’s Office.

An investigation may result in recovery of overpayments or remediation ranging from provider education to institution of a corrective action plan. Suspicion of fraud will result in referral to the appropriate state agencies.

How can you help?

You can help prevent fraud and abuse by:

Protecting your personal information

• Never give your insurance card or ID number to anyone other than a healthcare provider you are seeing for covered services; and
• Never give your card or your insurance ID number to anyone promising you free items or services or trying to sell you anything.

Keeping your Medicaid information current

• Notify MassHealth or the Health Connector if your program eligibility changes;
• Notify WellSense if your contact information changes; and
• Let providers know if you have other insurance or if you are seeking care due to an accident.

Identifying errors or fraud or abuse

• Fill out and return to WellSense any questionnaire you might receive from us asking if you have received certain services.

How to report fraud, waste, and abuse

If you suspect fraud, waste or abuse, you should report it to WellSense.

• Call the Fraud Hotline: 888-411-4959
• Email the Special Investigations Unit: FraudandAbuse@wellsense.org
• Fax the Special Investigations Unit: 866-750-0947
• Corporate Headquarters:  
  WellSense Health Plan 
  Attn: Special Investigations Unit 
  100 City Square, Suite 200 
  Charlestown, MA 02129  

WellSense treats all information associated with a case as confidential; it is shared only with individuals who have a legitimate need to receive it. Such individuals may include our Compliance Officer, legal department, and/or senior management and, in certain circumstances, state or federal agencies. If you prefer, you may report suspected fraud, waste or abuse anonymously.