Report Fraud

Health care fraud, waste and abuse hurts everyone including members, providers, taxpayers and CareSource. As a result, CareSource has a comprehensive fraud, waste and abuse program in our Special Investigations Department. Help us by reporting questionable situations. 

Some examples of provider activity that is monitored for fraud and abuse are:

• Providing unnecessary services to members
• Prescribing unnecessary drugs
• Failing to provide Medicaid managed care patients services that are comparable to those provided to patients with commercial or fee-for-service Medicaid coverage
• Billing members
• Inflating a bill for services
• Billing more than once for the same service
• Intentionally using improper codes on claims to receive a higher rate of reimbursement
• Billing for services not rendered

CareSource monitors member activity for fraud and abuse as well. Some examples are:

• Inappropriately using services such as selling prescribed narcotics or durable medical equipment
• Sharing a CareSource member ID card with someone who is not a CareSource member
• Submitting fraudulent Babies First coupons

CareSource also wants to know about fraudulent employee activity. Some examples are:

• Receiving gifts or kickbacks from CareSource vendors for goods or services purchased by CareSource
• Inappropriately marketing our company to potential CareSource members
• Behaving in an unethical or dishonest manner while performing company business

You can report fraud, waste and abuse to CareSource by:

• Calling the Fraud Hotline at 1-800-488-0134 and selecting the Fraud option.
• Sending an e-mail to fraud@caresource.com
• Sending a fax to 1-800-418-0248
• Writing a letter to:
  
  

  CareSource
  Attn: Special Investigations Unit
  P.O. Box 1940
  Dayton, OH 45401-1940

• Fill out the Fraud, Waste and Abuse Reporting Form. Your report may be anonymous; however, if you do not provide your name, we will not be able to call you back for more information. Your message will be kept confidential to the extent allowed by law.

Please give a detailed description of the activity, including the:

• Provider/member/employee name
• Provider/member number
• Date of activity
• All other pertinent information

When you report fraud, waste or abuse, please give us as many details as you can, including names and phone numbers. You may remain anonymous, but if you do we will not be able to call you back for more information. Your report will be kept confidential. 

Thank you for your assistance in keeping fraud out of health care.

False Claims Act

On February 8, 2006, President George W. Bush signed the Deficit Reduction Act of 2005 into law. The Deficit Reduction Act contains many provisions reforming Medicare and Medicaid that are designed to reduce program spending.  As an entity that offers Medicaid and Medicare coverage, CareSource is required to comply with certain provisions of the Deficit Reduction Act. One such provision requires us to provide you with information about the Federal False Claims Act, state False Claims Acts, and other state laws regarding Medicare and Medicaid Fraud. In addition, the law requires you and your contractors and agents to adopt our policy on fraud, waste, and abuse when handling CareSource business.

The Federal False Claims Act

Using the False Claims Act (the Act), you can help reduce fraud against the federal government. The Act allows everyday people to bring "whistleblower" lawsuits on behalf of the government- known as "qui tam" suits- against groups or other individuals that are defrauding the government through programs, agencies, or contracts.

The False Claims Act applies when a company or person:

• Knowingly presents a false or fraudulent claim for payment,
• Knowingly uses a false record or statement to get a claim paid,
• Conspires with others to get a false or fraudulent claim paid,
• Knowingly uses a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property.

"Knowingly" means acting with actual knowledge or with reckless disregard or deliberate indifference to the truth or falsity of information.

An example would be if a health care provider, such as a hospital or a physician knowingly "upcodes" or overbills; resulting in overpayment of the claim using Medicaid or Medicare dollars.

The time period for a claim to be brought under the False Claims Act is the later of:

• Within six years from the date of the illegal conduct, or 
• Within three years after the date the Government knows or should have known about the illegal conduct, but in no event later than ten years after the illegal activity.

Ohio State law

While Ohio has not passed its own false claims statute, there may nevertheless be liability under various Ohio laws regarding false or fraudulent claims with respect to Medicaid program expenditures, including:

• Medicaid Fraud, Ohio Revised Code Sec. 2913.40
• Medicaid Eligibility Fraud, Ohio Revised Code Sec. 2913.401
• Falsification, Ohio Revised Code Sec. 2921.13
• Offenses by Medicaid Providers, Ohio Revised Code Sec. 5111.03

CareSource policy

It is the policy of CareSource to detect and prevent any activity that may violate the federal False Claims Act or the state Medicaid fraud laws cited in this policy. If any employee, provider, delegated entity, subcontractor or agent has knowledge or information that any such activity may have taken place, they should contact the Special Investigations Unit. Information may be reported anonymously.

In addition, federal and state law and CareSource policy to prohibit any retaliation or retribution against persons who report suspected violations of these laws to law enforcement officials or who file "whistleblower" lawsuits on behalf of the government. Anyone who believes that he or she has been subject to any such retribution or retaliation should also report this to the Special Investigations Unit.