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WHAT IS FRAUD?
Healthcare Fraud is committed when someone intentionally submits or causes someone else to submit false or misleading information with the knowledge it could result in some unauthorized benefit to himself or some other person. Fraud is a crime and can result in imprisonment and fines.
WHO CAN COMMIT FRAUD?
Healthcare Fraud can be committed by physicians, dentists, labs, medical equipment suppliers, enrollees, and employees of the health plan.
WHAT IS HEALTHCARE ABUSE?
Healthcare Abuse is committed when a provider, enrollee, or health plan employee does something that is not consistent with sound fiscal, business or medical practices and results in an unnecessary cost to the Medicaid program.
WHAT ARE SOME OF THE TYPES OF FRAUD?
Examples of fraud include:
1) Billing for services not actually performed
2) Falsifying a patient's diagnosis to justify tests or other procedures that aren't medically necessary
3) Misrepresenting procedures performed to obtain payment for non-covered services
4) Upcoding or billing for a service that cost more than the one actually performed
5) Unbundling or billing each stage of a procedure as if it were a separate procedure
6) Waiving patient co-pays or deductibles and over-billing the managed care organization
7) TennCare recipients living out of state
8) Allowing someone other than yourself to use your TennCare I.D. card
HOW CAN YOU HELP TO PREVENT HEALTHCARE FRAUD?
1) Take an active role in your health by asking providers about the services you receive;
2) Question advertisements or promotions that offer free tests, treatment or services;
3) Be very careful about disclosing your insurance information;
4) Question charges that are more than your co-pay amount that you are asked to pay by a provider.
Certification of Mandatory False Claims Act Education Compliance:
Certification
Fraud & Abuse Training:
False Claims Act & Whistleblower Protection Presentations
Fraud & Abuse Policies:
Federal False Claims Act
Fraud & Abuse Reporting
Fraud & Abuse Round Table
Provider Fraud & Abuse Subgroup
Fraud & Abuse Compliance Plan
HOW TO REPORT SUSPECTED FRAUD AND/OR ABUSE:
PHONE: Local (901) 515-3468 or Out of State 1(800)-473-6523
MAIL:
TLC
Office Of Compliance
1407 Union Ave. Suite 200
Memphis, Tennessee 38104
EMAIL:fraudabuse@mmcc-tlc.com
To Goto TennCare Fraud & Abuse Site: Click Here
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