Fraud, waste and abuse prevention & training
If you identify
potential fraud, waste, or abuse, please report it to us immediately so that we
can investigate and respond appropriately.
Please see the How to Contact Us section of this guide for contact information.
Please note UnitedHealthcare expressly prohibits retaliation if a report
is made in good faith.
• Fraud Is a false
statement, made or submitted by an individual or entity, who knows that the
statement is false, and knows
that the false statement could result in some otherwise unauthorized benefit to
the individual or entity. These false statements could be verbal or
written.
• Waste Generally
means over-use of services, or other practices that result in unnecessary
costs. In most cases, waste
is not considered caused by reckless actions but rather the misuse of
resources.
• Abuse Generally
refers to provider, contractor or member practices that are inconsistent with
sound business, financial or medical
practices; and that cause unnecessary costs to the health care system.
Effective January 1,
2009, the Centers for Medicare & Medicaid Services (“CMS”) modified certain
rules and regulations of the
Medicare Advantage and the Part D programs. The rules state that a compliance
plan must include training, education, and effective lines of
communication between the compliance officer and the
organization’s employees, managers, directors, as well as first tier,
downstream and related entities. This change clarified that plan sponsors,
such as UnitedHealthcare, need to apply these training and communication
requirements to all entities they are partnering with to provide services in
Medicare Advantage or Part D programs.
As a contracted
provider for UnitedHealthcare’s Medicare Advantage programs, you are considered
a first tier or downstream entity and
are subject to this CMS requirement. It is our responsibility to ensure that your
organization is provided with appropriate training for your employees and
applicable subcontractors. To facilitate that, we will be providing your
organization with training materials, which will be made available on
UnitedHealthcareOnline.com.
Annually, your
organization must administer the training materials to your employees and
applicable subcontractors. This
annual training can be done using our materials or you may use your existing
training program and/or materials provided by another health plan as long
as that training meets the CMS requirements. Please maintain records of
the training (i.e. sign-in sheets, materials, etc). Documentation of the
training may be requested by UnitedHealthcare, CMS, or an agent of CMS to
verify the training was completed.
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