Fraud, Waste & Abuse Information and Hotline
Special Investigations Unit (SIU)
Health Partners Plans prohibits all illegal and/or unethical conduct by members, employees, and providers. Our Special Investigations Unit (SIU) proactively addresses questionable activity and investigates referrals of illegal and unethical conduct. Investigative findings are forwarded to state and/or federal law enforcement agencies for appropriate legal action upon a substantiated finding of fraudulent conduct.
Examples of Illegal and/or Unethical Conduct
- Providers up-coding claims or submitting claims for services not provided
- Providers providing false statement to obtain credentials (MediCheck)
- Providers paying members incentives for patronage
- Pharmacist paying provider kickbacks for referrals
- Members selling membership cards or allowing others to use their membership ID numbers to obtain services
- Members selling medications obtained through the program
- Members obtaining services or equipment not medically necessary for their conditions
- Employees selling Health Partners Plans' information
- Employees accepting money or gifts in exchange for manipulating some part of Health Partners Plans’ system
Definitions
Fraud: Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable federal or state law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the PH-MCO, a subcontractor, a provider, or a member, among others.
Waste: The overutilization of services or other practices that result in unnecessary costs. Waste is generally not considered caused by criminally negligent actions, but rather misuse of resources.
Abuse: Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or agreement obligations, including the requirements of state or federal regulations for health care in a managed care setting. Abuse also includes member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or provider.
Reporting Suspected Fraud, Waste or Abuse
If you suspect illegal and/or unethical activity among our members, employees or providers, call the SIU Hotline at 1-866-477-4848. Each call is evaluated by an investigator. All calls are confidential and may be made anonymously.
Other ways to report suspected fraud, waste or abuse include:
- Online(reports may be made anonymously): My Compliance Report online reporting tool (reports may be made anonymously)
- Email: SIUtips@jeffersonhealthplans.com
- CMS Medicare Hotline: 1-800-MEDICARE (1-800-633-4227)
- PA Department of Human Services Medicaid Hotline: 1-866-379-8477
- U.S. Department of Health and Human Services, Office of the Inspector General Hotline: 1-800-447-8477
