What is Abuse? What is Fraud?
Fraud and Abuse. Go to Search. What is Waste? Examples of Provider Fraud Billing for services that were not provided Billing for supplies that were not received Billing for more expensive services or procedures than were actually performed Billing more than once for the same medical service Billing for services for deceased individuals Unbundling, such as billing for services separately to receive a higher reimbursement rate Performing medically unnecessary services Services provided by und personnel Falsifying documentation, for example, medical records, caretaker timesheets Overprescribing Dispensing generic drugs but billing for brand-name drugs Giving or accepting something of value cash, gifts, services in return for medical services.
What is a Provider? Overpayments that are not returned within 60 days from the date the overpayment was identified can trigger a liability under the False Claims Act. Information on how to report or refund an improper payment. Providers shall perform self-audit and report overpayment and, when it is applicable, return overpayment to TennCare within 60 days from the date the overpayment is identified.
OPI collaborates with the Managed Care Contractors MCCslaw enforcement, and various state and federal agencies to ensure regulatory compliance and ability and protects the financial and health care service integrity of the TennCare program. It includes any act that constitutes fraud under applicable Federal or State law.
TennCare tn. Report shipments of medical supplies you never ordered or received. Abuse is the result of provider practices that are inconsistent with sound fiscal, business, or medical practices, resulting in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
Report any billing for equipment you never ordered or received. Provider Appellate Process.
Go to TN. Print This. An example of waste may include a provider ordering more lab tests than determined to be medically necessary. Fraud tn. Waste is generally understood to be overutilization, underutilization, or other misuse of resources that result in unnecessary costs to the Medicaid program and are not the result of a criminal or intentional act by the provider.
If you suspect fraud or abuse is being committed by someone who receives TennCare benefitsyou may report your concerns to the Office of Inspector General in one of the following ways: Call the Toll-Free Hotline or TennCare. Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception or misrepresentation could result in an unauthorized benefit to an individual or some other person.
An example of abuse may include improper billing practices, such as misrepresenting the level of services provided in order to submit claims for a higher paying code. Terminated Provider List. If you suspect fraud or abuse is being committed by someone who receives TennCare benefitsyou may report your concerns to the Office of Inspector General in one of the following ways:.
Ask your provider questions about the services you receive and why they are needed. Program Integrity. Providers include doctors, nurses, dentists, nursing homes, pharmacies, medical equipment supply companies, transportation companies, counselors, home health companies or anyone else that is paid by Medicaid for health care services.
If dates of service or the services billed are not accurate, report it. Review your Explanation of Benefits EOB for accuracy of the dates of services and the services you received.