Waste, Fraud & Abuse Prevention
It is the firm policy of Amerigroup that its subsidiaries, officers, directors and associates have an affirmative obligation to participate in efforts to detect, mitigate and/or prevent fraud, waste and abuse within the health care system. Participation includes reporting suspected fraud, waste and abuse as described in our attached Policy.
Amerigroup Waste, Fraud and Abuse Policy
Amerigroup maintains anonymous hotlines for the reporting of suspected fraud, waste and abuse. The reporting requirements are outlined in our Compliance Reporting policy. In addition to the anonymous hotlines, the CID maintains a Corporate Investigations email address (corpinvest@amerigroupcorp.com).
Hotline: 757-518-3633 or (extension: 3RISK)
Definitions
Fraud is the intentional deception or misrepresentation that an individual or entity makes knowing this could result in unauthorized benefits to that individual, entity or some other party. Fraud is not committed by accident or mistake.
Note: Failure to include material information is just as significant as adding false information.
Examples include:
- Billing for services not rendered
- Altering or falsifying documentation
- Paying or receiving a kickback for services
- Purposefully charging a fee for items that carried no cost (e.g., free drug samples)
Waste results in the expenditure of resources in excess of need. Waste can simply be the result of sloppy, careless or inefficient billing or treatment. This carelessness results in unnecessary costs being incurred by the Medicaid system. Unlike fraud, waste does not involve the intent to deceive or misrepresent.
Examples include:
- Unintentional duplicate claim submissions for the same service
- Improper coding that results in unnecessary payments
Abuse is an activity not consistent with generally accepted business, medical or fiscal standard practices. These incorrect billing practices would not be intentional.
Examples include:
- Billing for services not medically necessary
- Inappropriate or insufficient documentation to support services billed
- Quality of care issues that fail to meet professionally recognized standards
- Services mistakenly billed that should not be paid for by Medicaid
Amerigroup Associate Training
All associates are regularly trained on Fraud, Waste and Abuse to ensure understanding and compliance with the latest regulations and the spirit of the laws.