Fraud & Abuse
Noridian has a team devoted to combating fraud and abuse.
Our Benefit Protection team initially reviews any problems reported. Noridian performs anti-fraud activities in conjunction with two Zone Program Integrity Contractors (ZPICs). The ZPIC for Zone 1 (California, Hawaii and Nevada) is SafeGuard Services (SGS). The ZPIC for Zone 2 (Alaska, Arizona, Kansas, Idaho, Iowa, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming) is AdvanceMed.
ZPICs promote the integrity of Medicare through benefit integrity (fraud and abuse) functions. They help address fraud, waste and abuse by performing regional Medicare data analysis as well as comprehensive problem identification and research to identify potentially fraudulent Medicare providers. Additional responsibilities include coordination of benefit integrity activities among Medicare contractors in the region and dissemination of relevant benefit integrity information to these contractors, along with performing medical review of claims for benefit integrity purposes.
Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person. The most frequent kind of fraud arises from a false statement or representation that is material to entitlement or payment under the Medicare program. The violator may be a practitioner, physician, supplier, contractor employee or beneficiary. Examples of fraud include, but are not limited to the following:
- Billing for services or supplies that weren't provided
- Altering claims to obtain higher payments
- Soliciting, offering or receiving a kickback, bribe or rebate, i.e., paying for referral of clients
- Provider completing Certificates of Medical Necessity (CMN) for patients not known to the provider
- Suppliers completing CMNs for the physician
- Using another person's Medicare card to obtain medical care
In general, abuse describes behaviors or practices of providers, physicians or suppliers of services and equipment that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business or fiscal practices. The practices may, directly or indirectly, result in unnecessary costs to the program, improper payment or payment for services that fail to meet professionally recognized standards of care or which are medically unnecessary. Examples of abuse include, but are not limited to the following:
- Excessive charges for services or supplies
- Claims for services not medically necessary
- Breach of Medicare participation or assignment agreements
- Improper billing practices
Reporting Fraud and Abuse
If a supplier suspects fraud or abuse, please collect the following information and mail it to Noridian Benefit Protection:
- Date of service and name of the beneficiary
- Name of the physician and/or supplier
- Complete description of the problem
- Any documentation the supplier has that is related to the situation
- Name, address and phone number of the person making the complaint if it is someone other than the beneficiary
As an alternative, the supplier may contact the Supplier Contact Center and relay the above information to the customer service representative.
Medicare beneficiaries should report suspected fraud and abuse by calling 1-800-MEDICARE (1-800-633-4227).
An alternative for beneficiaries is to call the Office of the Inspector General (OIG).
It is current Hotline policy not to respond directly to written communications.
You may also submit your complaint using the OIG hotline online process.
A supplier is encouraged to implement a compliance program to ensure adherence to statutes, regulations, and program requirements.
A supplier may identify activities/claims/processes they deem questionable by the supplier as a result of an internal audit or compliance review. The supplier may choose to use the Self-Disclosure process to report this activity. This type of disclosure should be directly reported to the OIG.
Please see the OIG website for further information about this process.
Penalties for Fraud and Abuse
Fraud and abuse cases are routinely referred to the OIG for decisions on punishment. The mission of the OIG, as mandated by Public Law 95-452 (as amended), is to protect the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs. The OIG could use civil monetary penalty, criminal penalty, or administrative sanctions. Civil monetary policies may be imposed in the following cases, but may also be applied to other cases:
- An item or service is not provided as claimed
- An item or service claimed is false or fraudulent
- Medicare assignment provisions are violated
- An item or service is provided by an excluded person
Criminal penalties may be imposed in the following cases, but may also be applied to other cases:
- Soliciting, offering or receiving a kickback, bribe or rebate
- Knowingly and willingly making or causing to be made any false statement or misrepresentation in applying for a Medicare benefit or payment
Administrative sanctions may be used:
- Against an abusive practitioner/provider/supplier
- Against a practitioner/provider/supplier who consistently fails to comply with Medicare regulations
Last Updated Sep 15, 2016