Fraud, Waste, and Abuse
Magellan takes provider fraud, waste, and abuse seriously. Magellan promotes provider practices that are compliant with all federal and state laws. Our expectation is that providers will submit accurate claims, not abuse processes or allowable benefits, and exercise their best independent judgment when deciding which services to order for their patients.
Magellan does not tolerate fraud, waste, or abuse, either by providers or staff. Accordingly, we have instituted extensive procedures to combat these problems. These procedures are wide-ranging and multi-faceted, focusing on education, prevention, detection and investigation of all types of fraud, waste, and abuse in government programs.
Our policies in this area reflect that both Magellan and providers are subject to federal and state laws designed to prevent fraud and abuse in government programs (e.g., Medicaid and Medicare). Magellan complies with all applicable laws, including the Federal False Claims Act, state false claims laws, applicable whistleblower protection laws, the Deficit Reduction Act of 2005, the American Recovery and Reinvestment Act of 2009, the Patient Protection and Affordable Care Act of 2010 and applicable billing requirements for state and federally funded health care programs.
Understanding Fraud, Abuse, Waste, and Overpayment
Fraud
An intentional deception or misrepresentation made by a person with the knowledge that deception could result in some unauthorized benefit to him/her or some other person. It includes any act that constitutes fraud under applicable federal or state law.
Examples include:
- Intentionally billing for services that were not provided
- Falsifying signatures
- Rounding up time spent with a member
- Altering claim forms
Abuse
Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to government-sponsored programs, and other health care programs/plans, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to federally and/or state-funded health care programs.
Reporting Fraud, Waste, and Abuse
Reports made to Magellan can be submitted via one of the following methods:
- Special Investigations Unit Hotline: 1-800-755-0850
- Special Investigations Unit Email: SIU@MagellanHealth.com
- Corporate Compliance Hotline: 1-800-915-2108
- Compliance Unit Email: Compliance@MagellanHealth.com
Contact Information for Fraud and Abuse Reporting
If you have knowledge of suspected Medicaid provider noncompliance, or of substandard quality of care for services paid for under the Early Supports and Services Program, there are four ways to report this information to the state:
- Call toll-free 1-800-488-2917 for Provider Fraud Complaints or 1-888-342-6207 for Recipient Fraud complaints. Call long distance 1-318-487-5138 for Recipient Fraud complaints.
- Complete the appropriate form online and submit it electronically.
- Provider Fraud Form
- Member Fraud Form
- Print out the appropriate form (above), complete it, and mail it to:
Provider and Member Fraud Complaint
Louisiana Department of Health
Customer Service Unit
P.O. Box 91278
Baton Rouge, LA 70821-9278
- Fax the completed form (above) to 225-216-6129 for provider fraud complaint or 225-389-2610 for member fraud complaint
For more information about how to report fraud, waste, and/or abuse including overpayments see the Magellan Health website www.magellanhealth.com for Magellan’s FALSE CLAIMS LAWS AND WHISTLEBLOWER PROTECTIONS DRA Compliance Statement and link to the State False Claim Acts for state-by-state information about how to report fraud, waste, and/or abuse including overpayments