Fraud, Waste and Abuse Policy

Evidence of fraud will be submitted to the Surveillance and Integrity Review (SIRS) Unit of DHS.
Fraud of Medicaid funding is a felony.

Fraud, Waste and Abuse Defined

Fraud: an intentional act of deception, misrepresentation or concealment in order to gain
something of value. Examples include:

• Billing for services that were never rendered;
• Billing for services at a higher rate than is actually justified; and
• Deliberately misrepresenting services, resulting in unnecessary cost to the Medicare program, improper payments to providers or overpayments.

Waste: over-utilization of services (not caused by criminally negligent actions) and the misuse
of resources.
Abuse: excessive or improper use of services or actions that are inconsistent with acceptable
business or medical practice. “Abuse” refers to incidents that, although not fraudulent, may
directly or indirectly cause financial loss. Examples include:

• Charging in excess for service or supplies; and
• Providing medically unnecessary services; and
• Billing for items or services that should not be paid for by Medicare.

Fraud, Waste and Abuse Compliance Training

We have completed the required training by reviewing the appropriate material available at www.mnhealthplans.org.

Fraud, Waste and Abuse Compliance Plan

The following applies to detect, prevent and correct fraud, waste, and abuse as required by applicable state and federal laws and
regulations:

Standards of Conduct

• Fraud will not be tolerated;
• Providing false information on a timesheet is fraud;
• Billing for services not provided is fraud;
• Prohibited from giving or receiving any type of kick back; and
• Failure to refund or return overpayments is fraud.

Compliance Plan (measures to detect, prevent and correct fraud, waste and abuse)

• Random audits of timesheets for overuse and fraud;
• Background checks to determine whether providers or office staff have been
• convicted of health care fraud;
• Open-door policy to report possible misuse of Medicare or Plan funds; and random audits of billing claims (billing code must reflect the services provided).

Training (addresses detection, preventing and correcting fraud, waste and abuse)

• Policy and Procedures which address fraud and the reporting of fraud, waste and abuse;
• Employee contract which addresses fraud and abuse;
• Responsible Party contract which addresses detection, prevention and correcting fraud, waste and abuse;
• Time sheets which address issues of fraud and abuse.

Disciplinary Actions

• Employee who commits fraud may be terminated;
• Services could be terminated for a client who commits fraud; and
• Committing fraud may result in jail time, probation, deportation, fines, exclusion from services or work in this field or a job requiring a background study

Reporting Fraud

• Any employee and/or Responsible Party can file a claim of fraud, abuse or waste to Accra;
• Claims will be addressed by a member of the Accra management team within 5 business days from receiving the claim;
• The Accra Incident Review Team reviews incidents of fraud monthly; and
• Compliance concerns, suspected or actual misconduct involving Medicaid programs will be reported to SIRS.

Responding to Detected Offenses and Corrective Action

• Offenses will be reported to SIRS;
• Over payment will be returned to the funding source; and
• Retraining to prevent similar offenses.

Avoiding Fraud

The CDCS program is funded by Federal Medical Assistance. It is a crime to
provide false information for Medical Assistance payments.

The Employee

• Can only be paid for work done when the employee is physically present and providing necessary care for the consumer;
• Cannot be asked or told to split pay with the Consumer or Responsible Party;
• Cannot work when the Consumer is at a HOSPITAL, school, receiving in-patient care, a nursing home, respite care facility, or is incarcerated; and
• Cannot submit a time sheet for hours not worked.

Conduct on the Job (the employee, when at work)

• Shall provide care as specified in the care plan and shall follow written and oral directions from the Responsible Party;
• Shall arrive on time and not leave work early;
• Shall not steal from or mistreat the Consumer;
• Shall not consume alcohol or be under the influence of any illegal drugs; and
• Shall not use cell phones, text message or engage in personal business.

Illegal Payment Schemes

• Both the Employee and the Responsible Party shall be held accountable for signing a fraudulent time sheet
• The following conduct is not acceptable and is fraudulent:
  • The Responsible Party signs a time sheet for a certain payroll period when the Employee did not actually work those hours that are shown on that time sheet at the times and dates indicated. (As an example, the Employee and Responsible Party send in a time sheet showing the Employee worked on Wednesday of the prior week. On that Wednesday the Employee was out on vacation in another state and could not have actually worked on that day.)
  • The time sheet is signed before hours are actually worked.

Identity Theft

Using an identification that does not belong to that person to obtain payment
and/or services.

False Claims Act

Prohibits any person from knowingly presenting or causing a fraudulent claim
for payment.

Anti-Kickback Statute

Makes it a crime to knowingly and willfully offer, pay, solicit, or receive, directly or indirectly, anything of value to induce or reward referrals of items or services reimbursable by a Federal health care program.

Reporting Fraud, Waste and Abuse

Everyone has the right and responsibility to report actual and possible fraud, waste or abuse. You may report anonymously and retaliation is prohibited when you report a concern in good faith. Report issues or concerns to: Accra’s Whistleblower hotline; and/or

Additional Resources

Federal government websites are sources of information regarding detection, correction and prevention of fraud, waste and abuse:

Accra Care, Inc.
12600 Whitewater Dr, Suite 100,
Minnetonka, MN 55343
952-935-3515