Fraud, Waste, and Abuse

Provider fraud training and attestation

Keystone First – CHIP is committed to detecting and preventing the acts of fraud, waste, and abuse. Take your mandatory provider training (PDF). Please remember to fill out the attestation after completing the training.

Defining fraud, waste, and abuse

Keystone First – CHIP receives state and federal funding for payment of services provided to our Enrollees. In accepting claims payment from Keystone First – CHIP, health care providers are receiving state and federal program funds and are therefore subject to all applicable federal and/or state laws and regulations relating to this program.

Violations of these laws and regulations may be considered fraud or abuse against the CHIP program. Providers are responsible for knowing and abiding by all applicable state and federal laws and regulations.

Fraud

Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable federal or state law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the CHIP-MCO, a subcontractor, a provider, or an Enrollee, among others.

Waste

The overutilization of services or other practices that result in unnecessary costs. Generally, not considered caused by criminally negligent actions, but rather misuse of resources.

Abuse

Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to CHIP, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or agreement obligations (including the RFA, Agreement, and the requirements of state law or federal regulations) for health care in a managed care setting. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider or entity has not knowingly or intentionally misrepresented facts to obtain payment. The abuse can be committed by the CHIP-MCO, subcontractor, provider, state employee, or an Enrollee, among others. Abuse also includes Enrollee practices that result in unnecessary cost to CHIP, the CHIP-MCO, a subcontractor, or provider.

Examples of fraud, waste, and abuse

Provider fraud, waste, or abuse includes but is not limited to:

• Billing for services not furnished
• Submitting false information to obtain authorization to furnish services or items to CHIP Enrollees
• Accepting kickbacks for patient referrals
• Violating physician self-referral prohibitions
• Billing for a more costly service than the one performed
• Providing, referring, or prescribing services or items that are not medically necessary
• Providing services that do not meet professionally recognized standards

Examples of Enrollee fraud, waste, or abuse

Enrollee fraud, waste, or abuse includes but is not limited to:

• Fraudulent activities (forged/altered prescriptions or borrowed cards)
• Repetitive emergency room visits with little or no PCP intervention or follow-up
• Same/similar services or procedures in an outpatient setting within one year
• An Enrollee using someone else’s insurance card to receive care
• Forging or altering prescriptions/medications, trafficking SNAP benefits, or taking advantage of the system in any way

If upon review by Keystone First – CHIP there is an indication of recipient misuse, abuse, or fraud, the Enrollee will be placed on the Recipient Restriction Program, which means the Enrollee(s) can be restricted to a single PCP, pharmacy, or hospital/facility for a period of five years.

Restriction to one network provider of a particular type will help ensure coordination of care and facilitate more focused medical management.

Screening employees for federal exclusion

All individuals and entities whose functions are a necessary component of providing items and services to CHIP Enrollees, and who are involved in generating a claim to bill for services or are paid by CHIP, should be screened for exclusion from the federal health care programs before you employ and/or contract with them. If hired, they should be rescreened on an ongoing monthly basis to capture exclusions and reinstatements that have occurred since the last search. Examples of individuals or entities that providers should screen for exclusion include but are not limited to:

• An individual or entity who provides a service for which a claim is submitted to CHIP
• An individual or entity who causes a claim to be generated to CHIP
• An individual or entity whose income derives all or in part from CHIP funds, directly or indirectly
• Independent contractors if they are billing for CHIP services
• Referral sources, such as providers who send an Enrollee to another provider for additional services or a second opinion related to a medical condition

CHIP providers who employ or enter into contracts with individuals or entities to provide items or services to CHIP Enrollees when those individuals or entities are excluded from participation in any Medicare, Medicaid, or other federal health care programs are subject to termination of their enrollment in and exclusion from participation in the CHIP program and all federal health care programs, recoupment of overpayments, and imposition of civil monetary penalties.

View the list of excluded individuals/entities (LEIE) database.

The System for Award Management (SAM) is an official website of the U.S. government. Search for entity registration and exclusion records.

Fraud and abuse laws and regulations

Additional resources

Waste and recovery

Examples of waste include but are not limited to:

• Overpayment due to incorrect set-up or update of contract/fee schedules in the system
• Overpayments due to claims paid based upon conflicting authorizations or duplicate payments
• Overpayments resulting from incorrect revenue/procedure codes or retroactive third-party liability/eligibility

The Payment Integrity Department is responsible for identifying and recovering claim overpayments. The department performs several operational activities to ensure the accuracy of providers’ billing submissions. The department utilizes internal and external resources to prevent the payment of claims associated with waste and to initiate recovery when overpaid claims are identified.

As a result of these claims accuracy efforts, providers may receive letters from Keystone First – CHIP or on behalf of Keystone First – CHIP, regarding recovery of potential overpayments and/or requesting medical records for review.

Please refer to our Provider Manual or the letter you received to learn how to return overpayments. You should also use the contact information provided in the letter to expedite a response to questions or concerns.　

References and training

• Centers for Medicare & Medicaid Services: Fraud & abuse