For Members

Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on taxpayers and the health care system. We are committed to stopping health care fraud. To help us protect you against fraudulent claims and practices, we have included examples of activities you should look for:

• Does your Explanation of Benefits (EOB) show a charge that you did not receive?
• Did you get a phone call from an unknown caller offering low cost or free medical services? Did the caller ask for your personal information, such as your Social Security number, Medicare number, or date of birth?
• Do you know someone who changed or forged a prescription?
• Do you know someone who visits multiple doctors to get the same prescription?
• Do you know someone who fills a prescription and then sells the medication?
• Does a provider primarily write for narcotics or controlled substances?
• Is a provider prescribing a higher quantity than medically necessary for a condition?
• Is a provider giving unnecessary services?
• Does a provider bill for services not provided?
• Are medications expired, fake, or diluted?
• Are generics given when the prescription requires that brand be dispensed?
• Does a pharmacist provide less than the prescribed quantity and bill for the full amount?
• Are there claims for prescriptions that you never picked up?

If you see any of these activities, please contact us immediately. We will look into and work with State and Federal government agencies about your concerns.

Useful Information

Below are documents and websites with tips and important information on how to protect yourself against fraudulent activities. This includes how to spot fraud and how to report your concerns.

For Providers

Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on tax payers and the health care system. We are committed to combating health care fraud. You can help us to prevent, detect, and correct noncompliance and fraud, waste, and abuse (FWA).

Compliance Reporting

If you suspect noncompliance or FWA activities, you must report them to us by calling (800) 624-6052 ext. 2580 or emailing providerservicerep@pacificsource.com. You may also report anonymously by contacting EthicsPoint (a PacificSource vendor) 24 hours a day/seven days a week at (888) 265-4068.

Here are some common examples of noncompliant and FWA activities:

• Submitting claims when you are on the Office of Inspector General's (OIG) exclusion list
• Billing multiple payers for the same service, except as required for coordination of benefit
• Inappropriate up-coding
• Billing for services not rendered
• Providing excessive or unnecessary services
• Prescription forging or altering
• Receiving illegal payments or other benefits to prescribe certain medications
• Prescription drug shorting
• Providing false or misleading information to justify coverage
• Dispensing expired or adulterated prescription drugs
• Illegal distribution of free samples
• Billing for non-covered services as covered
• Stolen prescriber Drug Enforcement Agency (DEA) number or prescription pad

Annual Compliance Training

You and your employees are required to take general compliance and FWA training annually. If you have met the fraud, waste, and abuse certification requirements through enrollment into the Original Medicare program, you do not have to take the FWA Training. If you and your employees have taken the training for other Medicaid Managed Care, or Medicare Advantage health plans, you do not have to take PacificSource’s training.

For your convenience, we have provided you with the following training modules.

FWA Prevention Handbook
OIG Compliance and FWA Training

You must ensure that all of your employees and any downstream entities (i.e., subcontractors) take both of these CMS-approved training modules annually and read our Compliance Program and Standards of Conduct. All new employees and any downstream entities (i.e., subcontractors) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log to track your completion. If your employees and any downstream entities (i.e., subcontractors) have taken a CMS-approved training for other Medicaid Managed Care health plans, you do not have to take PacificSource’s CMS-approved training. However, they must still document their completion using the other health plan’s Training Attendance Log, or a modified version thereof. You do not need to send anything to PacificSource. However, your proof of training attendance and completion will be subject to PacificSource audit and verification.

Questions

If you have any questions about the content of this page, you may contact your provider service representative at (800) 624-6052 ext. 2580 or providerservicerep@pacificsource.com.

Useful Information

Below are documents and websites that provide you with tips and information on how to protect you and your patients against fraudulent activities, including how to detect and report them.

For Contractors

Health care fraud is a growing problem. It drives up the cost of health care, and puts a burden on tax payers and the health care system. We are committed to combating health care fraud. You can help us to prevent, detect and correct noncompliance and fraud, waste and abuse (FWA).

Compliance Reporting

If you suspect noncompliance or FWA activities, you must report them by contacting us. You may also report anonymously by contacting EthicsPoint (a PacificSource vendor) 24 hours a day, seven days a week at (888) 265-4068.

Here are some common examples of noncompliant and FWA activities:

• Performing work when you are on the Office of Inspector General's (OIG) exclusion list
• Failing to meet your contractual performance standards
• Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule
• Not paying claims accurately or timely
• Failing to send member notices timely
• Billing multiple payers for the same service, except as required for coordination of benefit
• Inappropriate up-coding
• Billing for services not rendered
• Providing excessive or unnecessary services
• Prescription forging or altering
• Receiving illegal payments or other benefits to prescribe certain medications
• Prescription drug shorting
• Providing false or misleading information to justify coverage
• Dispensing expired or adulterated prescription drugs
• Illegal distribution of free samples
• Billing for non-covered services as covered
• Stolen prescriber Drug Enforcement Administration (DEA) number or prescription pad

Annual Compliance Training

You and your employees are required to take general compliance and FWA training. If you and your employees have taken the training for other Medicaid Managed Care, or Medicare Advantage health plans, you do not have to take PacificSource’s training.

For your convenience, we have provided you with the following training modules.

FWA Prevention Handbook
OIG Compliance and FWA Training

You must ensure that all of your employees and any downstream entities (i.e., subcontractors) take both of these CMS-approved training modules annually and read our Compliance Program and Standards of Conduct. All new employees and any downstream entities (i.e., subcontractors) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log to track your completion. If your employees and any downstream entities (i.e., subcontractors) have taken a CMS-approved training for other Medicaid Managed Care health plans, you do not have to take PacificSource’s CMS-approved training. However, they must still document their completion using the other health plan’s Training Attendance Log, or a modified version thereof. You do not need to send anything to PacificSource. However, your proof of training attendance and completion will be subject to PacificSource audit and verification.

Questions

If you have any questions about the content of this page, please contact us.

Useful Information

Listed below are documents and websites that provide you with tips and information on how to protect yourself against fraudulent activities, including how to detect and report them.