Identifying and reporting fraud, waste and abuse is everyone’s responsibility. Health Partners Plans takes this very seriously and holds all employees, members and providers accountable for reporting all concerns of suspected fraud, waste and abuse.

Providers in our network are responsible for auditing themselves and reporting any findings that would have resulted in an overpayment or underpayment to them.

For more information on provider self-disclosure and self-auditing protocols:

• U.S. Department of Health and Human Services (HHS)
• Pennsylvania Department of Human Services (DHS)

False Claims Act

The False Claims Act is the single most important tool U.S. taxpayers have to recover the billions of dollars stolen through fraud by U.S. government contractors, including Medicare and Medicaid providers, every year. Under the False Claims Act, those who knowingly submit or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of a minimum of $11,665 and a maximum of $23,331 (as of June 2020) per false claim.

There are a number of resources for reporting Medicare/Medicaid/CHIP fraud or suspicious activity:

• Health Partner Plans SIU Hotline: 1-866-HP-SIU4U (1-866-477-4848)
• CMS Medicare Hotline: 1-800-MEDICARE (1-800-633-4227)
• Department of Human Services Medicaid Hotline: 1-866-379-8477 or 1-844-DHS-TIPS
• Report suspected Medicaid provider fraud or abuse. You can report anonymously.
• Health & Human Services Office of the Inspector General: 1-800-HHS-TIPS (1-800-447-8477); TTY 1-800-377-4950

Qui Tam Whistleblower Provisions

The False Claims Act contains qui tam, or whistleblower, provisions. Qui tam is a unique mechanism in the law that allows citizens with evidence of fraud against government contracts and programs to sue, on behalf of the government, in order to recover the stolen funds. In compensation for the risk and effort of filing a qui tam case, the citizen whistleblower or "relator" may be awarded a portion of the funds recovered, typically between 15 and 25 percent. A qui tam suit initially remains under seal for at least 60 days during which the Department of Justice can investigate and decide whether to join the action.

The False Claims Act Employment Protections

If an employee is fired, demoted, harassed, or otherwise discriminated against for filing a False Claims Act suit, protections for whistleblowers may include: reinstatement; double back pay; and compensation for any special damages including litigation costs and reasonable attorneys' fees.

Affordable Care Act Expansion of the False Claims Act

Under the Affordable Care Act, violations of the Anti-Kickback Statute are per se violations of the False Claims Act. This means even unintentional violations of the statute can be grounds for fraud liability. Among other examples, deliberate ignorance no longer can be claimed, nor do providers have the ability to argue that they did not have the requisite intent to commit fraud. In addition, overpayments must be reported and returned to CMS within 60 days of identification.