What includes any misuse of resources such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare program?

Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program. (18 U.S.C. § 1347)

Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse is payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.

Fraud, waste and abuse training

Contracted healthcare providers and third parties supporting Humana’s Medicare and/or Medicaid products must train their employees and those supporting them to meet certain contractual obligations to Humana.

This includes:

• developing training on combating fraud, waste and abuse or using another training to meet that educational requirement.
• tracking the training

Note: To assist your organization, Humana material from the Standards of Conduct and Compliance Policy documents referenced further down this page may be integrated within the fraud, waste and abuse training or used as supplemental material.

*CMS designates these as first tier, downstream or related entities (FDRs).

Additional compliance program requirements for FDRs

Additional compliance program requirements for FDRs supporting Humana’s Medicare and/or Medicaid products are outlined in, but not limited to, the documents listed in subsequent sections of this page.

Standards of conduct

Here we have posted our “Ethics Every Day for Contracted Healthcare Providers and Third Parties”, which is closely aligned with Humana's standards of conduct for its employees. We invite contracted healthcare providers and third parties to review this information as soon as possible.

Ethics Every Day for Contracted Healthcare Providers and Third Parties

Ethics Every Day for Contracted Healthcare Providers and Third Parties – English

Ethics Every Day for Contracted Healthcare Providers and Third Parties – Spanish

Compliance Policy

This policy communicates Humana's strong and explicit organizational commitment to conducting business ethically, with integrity and in compliance with applicable laws, regulations and requirements. Humana requires its contracted healthcare providers and third parties to uphold a similar commitment to ethical conduct and assure that they, their employees and downstream entities who support Humana comply with the guiding principles outlined in this policy.

Compliance Policy for Contracted Healthcare Providers and Third Parties

Compliance Policy for Contracted Healthcare Providers and Third Parties – English

Compliance Policy for Contracted Healthcare Providers and Third Parties – Spanish

How to report fraud, waste and abuse

If you suspect fraud, waste or abuse in the healthcare system, you must report it to Humana and we'll investigate. Your actions may help improve the healthcare system and reduce costs for our members, customers and third parties.

To report suspected fraud, waste or abuse, you can contact Humana in one of these ways:

• Phone: English 1-800-614-4126
• Fax: 1-920-339-3613
• E-mail:
• Mail: Humana, Special Investigation Unit, 1100 Employers Blvd., Green Bay, WI 54344
• Ethics Help Line: 1-877-5-THE-KEY (1-877-584-3539)
• Ethics Help Line reporting website: www.ethicshelpline.com

You have the option for your report to remain anonymous. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, Humana corporate law department, market medical directors or Humana senior management).

Another option is to submit the Special Investigations Referral Form online, by filling out the form using the link below.

• Investigations Referral Form

If you are a medical, dental or pharmacy provider, and have a concern previously reported to SIU, you can follow up by filling out the Request to contact SIU form.

• Request to Contact SIU Form (English)
• Request to Contact SIU Form (Spanish)

SIU tools and resources

Humana's SIU utilizes software tools that help find and prevent healthcare fraud. This fraud detection software also allows us to review our claims for possible fraud before payment.

SIU references the following resources to support its investigations:

What we do

Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:

• Contact with relevant parties to gather information. This may include contacting members to get a better understanding of the situation. For example, we may contact a member to ask about a visit with his or her physician. We may ask the member to describe the services provided, who provided the care, how long the member was at the office, etc.
• Requests for medical, dental or pharmacy records. We do this to validate that the records support the services billed. It's important that the healthcare provider submits complete records as requested. We rely on this information to make a fair and appropriate decision.
• Notification of suspected fraud and abuse to law enforcement and CMS, if applicable, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare Part C (medical) and Part D (prescriptions), and any other applicable state and/or federal agencies.

Most common coding and billing issues

Some of the most common coding and billing issues are:

• Billing for services not rendered
• Billing for services at a frequency that indicates the provider is an outlier as compared with their peers
• Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
• Billing for services that are actually performed by another provider
• Up-coding
• Modifier misuse, for example modifiers 25 and 59
• Unbundling
• Billing for more units than rendered
• Lack of documentation in the records to support the services billed
• Services performed by an unlicensed provider but billed under a licensed provider's name
• Alteration of records to get services covered

State Fraud Warning Statements

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Activities that are considered fraud, waste and abuse by members, practitioners or care providers hurts everyone – SHL, taxpayers, members and providers. Combating fraud, waste and abuse is the responsibility of members, healthcare providers and insurers alike. It is your responsibility to report members or other providers you suspect are committing fraud or abuse. Your assistance in notifying us and cooperating with any potential fraud or abuse occurrence is vital and appreciated in conjunction with our mutual ongoing efforts to coordinate the most effective health outcomes possible for our members.

Definitions of Fraud, Waste and Abuse

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.

Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.

Examples of Fraud, Waste and Abuse include:

Administrative or Financial

• Kickbacks.
• Falsifying credentials.
• Fraudulent credentials.
• Fraudulent enrollment practices.
• Fraudulent third party liability reporting.
• Fraudulent recoupment practices.

Falsifying Claims/Encounters

• Alteration of a claim.
• Incorrect coding.
• Double billing.
• False data submitted

Falsifying Services

• Billing for services or supplies not provided.
• Misrepresentation of services/supplies.
• Substitution of services.

Member issues

• Resource misrepresentation (transfer and/or hiding).
• Residency.
• Household composition.
• Citizenship status.
• Unreported income.
• Misrepresentation of medical condition.
• Failure to report third party liability.

If you identify potential fraud, waste or abuse, please report it to us immediately so that we can investigate and respond appropriately.  There are multiple reporting methods including:

SHL Provider Services - 702-242-7088

The Compliance & Ethics Help Center

–Phone: 1-800-455-4521 (US)

–Online: UnitedHealthgroup Compliance & Ethics HelpCenter

–The Help Center is available 24 hours a day, 7 days a week.

Health Care Fraud Tip Line – 1-866-242-7727

UnitedHealth Group Compliance & Ethics Office

–Phone: 1-952-936-7463

–Email:

Integrity of Claims, Reports and Representation to Government Entities

The Deficit Reduction Act of 2005 (DRA) was signed into law in early 2006. The DRA encourages states to have in place false claims legislation. It further requires that any entity receiving annual Medicaid payments of $5 million or more to provide written policies available to all employees, contractors and agents (including providers), detailed information about the False Claims Act and any state laws that pertain to civil or criminal penalties for making false claims and statements, and the whistleblower protection under such laws, including the role of such laws in preventing and detecting fraud, waste and abuse in federal health care programs.

A number of federal and state regulations govern information provided to the government, including the Federal False Claims Act, State False Claims Acts and other regulations and protections. SHL requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid. Federal and state governments have adopted a number of statutes to deter and punish misrepresentations with regard to health care programs. Failure to comply with these laws could result in civil and criminal sanctions imposed by government entities and SHL.

Required Training

As part of an effective Compliance Program, CMS requires Medicare Advantage (MA) Organizations and Part D Plan Sponsors, including SHL, to annually communicate specific Compliance and Fraud, Waste and Abuse (FWA) requirements to their employees, including the CEO, senior administrators or managers, and for governing body members, and for first tier, downstream, and related entities” (FDRs), which include contracted physicians, health care professionals, facilities and ancillary providers, as well as delegates, contractors, and related parties.

The required education, training, and screening requirements to which we – and you – are subject include the following:

Standards of Conduct Awareness:

FDRs working on Medicare Advantage and Part D programs – including contracted providers – must provide a copy of their own or the UnitedHealth Group’s (UHG’s) Code of Conduct  (found at the UnitedHealthgroup website (PDF)).

to their employees (including temporary workers and volunteers), the CEO, senior administrators or managers, governing body and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA or Part D benefits or services within 90 days of hire and annually thereafter (by the end of the year).

What You Need to Do for Standards of Conduct Awareness:

Provide your own or the UHG’s Code of Conduct as outlined above and maintain records of distribution standards (i.e. in an email, website portal or contract, etc.) for 10 years. Documentation may be requested by UnitedHealthcare or CMS to verify compliance with this requirement.

Fraud, Waste, and Abuse and General Compliance Training:

FDRs working on Medicare Advantage and Part D programs – including contracted providers – must provide Fraud, Waste, and Abuse (FWA) and General Compliance training within 90 days of employment and annually thereafter (by the end of the year) to their employees (including temporary workers and volunteers), CEO, senior administrators or managers, and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA or Part D benefits or services.

Effective January 1, 2016, CMS has amended the regulations to mandate  only the use of CMS published training materials by FDRs of a contracted Medicare plan sponsor. FDRs cannot alter the published CMS training material content; however, CMS will allow FDRs to download CMS training material and add content and topics specifics to your organization. The CMS standardized FWA training  and education module is available through the CMS Medicare Learning Network (MLN) at cms.gov. 

FDRs meeting the FWA certification requirements through enrollment in the fee-for-service (Parts A or B) Medicare program or accreditation as durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Provider are deemed by CMS rules to have met the training and education requirements.

It is our responsibility to make sure that your organization has access to appropriate training. To facilitate that, we are providing you information on the CMS Parts C and D FWA and General Compliance training module. This module is available at the Centers for Medicare & Medicaid Services website.

What You Need to Do for FWA and Compliance Training:

Administer FWA and General Compliance training as outlined above and maintain a record of completion (i.e., method, training materials, dated employee sign-in sheet(s), employee attestations or electronic certifications from employees that include the date of the training) for 10 years. Documentation may be requested by UnitedHealthcare or CMS to verify compliance with this requirement.

Exclusion Checks:

FDRs must review federal exclusion lists (HHS-OIG and GSA)  and state exclusion lists, as applicable, prior to hiring/contracting with employees (including temporary workers,  volunteers, and consultants), the CEO, senior administrators or managers, and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA and Part D benefits or services to make sure that none are excluded or become excluded from participating in Federal health care programs.

FDRs must continue to review the federal and state exclusion lists on a monthly basis thereafter. For more information or access to the publicly accessible excluded party online databases, please see the following links:

Health and Human Services – Office of the Inspector General OIG List of Excluded Individuals and Entities (LEIE)

General Services Administration (GSA) Excluded Parties Lists System

What You Need to Do for Exclusion Checks:

Review applicable exclusion lists as outlined above and maintains a record of exclusion checks for 10 years. Documentation of the exclusion checks may be requested by UnitedHealthcare or CMS to verify that checks were completed.