Report Fraud Waste and Abuse

Compliance Hotline: 1-833-220-9970
Website: https://spbm-medicaid-ohio.ethicspoint.com/
Email: OH_MCD_Compliance@GAINWELLTECHNOLOGIES.COM

All reports are investigated and remain confidential to the extent permitted by law.  To help us investigate please include a detailed description of the activity and include:

•Provider/Member/Employee name and number (if you have a number available)

•Date of activity or incident

•As much detail about your concern as possible and any relevant information you have.

Reports made via the Compliance Hotline or Website may be done so anonymously.  Please note that reporting via email is not anonymous. 

The Compliance Hotline and Website are administered by EthicsPoint. Please click the link for Frequently Asked Questions to learn more about EthicsPoint. 

Additional Reporting Options:

You may report any potential fraud, waste, or abuse activities directly to the State of Ohio using one of the following options:
Ohio Department of Medicaid  
Phone: (614) 466-0722 or toll free 1-800-324-8680
Website: Reporting Suspected Medicaid Fraud | Medicaid (ohio.gov)

Ohio Medicaid Fraud Control Unit (MFCU)
Fax: 1-877-527-1305
Website:  Report Medicaid Fraud - Ohio Attorney General Dave Yost

You may report any potential fraud, waste, or abuse activities directly to the Federal Government

U.S. Department of Health and Human Services, Office of the Inspector General
Toll Free 1-(800) 447-8477
Website: https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx

Gainwell is committed to protecting the integrity of the Ohio Medicaid Program.  Medicaid fraud, waste, and abuse (FWA) negatively impacts our members, providers, and community.  Gainwell has invested in a comprehensive program to prevent, detect, and report any potential fraud, waste, or abuse activities.  You can help us by reporting any suspicious activity and we will investigate each report to ensure the Ohio Medicaid Program is protected .

Understanding FWA is key to prevention and detection.  You will find the definitions and examples below.

Fraud
An intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person.  It includes any act that constitutes fraud under applicable federal or state law. To be considered fraud the act must demonstrate that a person or entity knowingly submitted, or caused to be submitted, false claims or misrepresentations of fact to obtain a government funded health care payment for which no entitlement would otherwise exist.

Examples of Medicaid Fraud:
 

·Intentionally billing for unnecessary medical services or items 

·Intentionally billing for services or items not provided 

·Unbundling: billing for multiple codes for a group of procedures that are covered in a single global billing code 

·Upcoding: billing for services at a higher level of complexity than provided 

·Card sharing: knowingly treating and claiming reimbursement for someone other than the eligible beneficiary. Member sharing their Medicaid ID card with someone else so they can obtain medical services. 

·Collusion: knowingly collaborating with beneficiaries to file false claims for reimbursement.  Members helping their doctors file claims by having tests done you do not need. 

·Drug Diversion: writing unnecessary prescriptions or altering prescriptions to obtain drugs for personal use or to sell them.  Member altering a doctor's prescription, going to multiple doctors to get more of the same drug, or selling their drugs to others. 

·Kickbacks: offering, soliciting, or paying for beneficiary referrals for medical services or items.  Members accepting payment from their doctor for referring other beneficiaries for medical services. 

·Multiple cards: knowingly accepting multiple Medicaid ID cards from a beneficiary to claim reimbursement.  Members altering or duplicating their Medicaid ID card and using it or selling it for someone else to use. 

·Program Eligibility: Knowingly billing for an ineligible beneficiary. Member providing incorrect information to qualify for Medicaid. 

Waste

Practices that directly, or indirectly result in unnecessary costs such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources. 

Examples of Medicaid Waste

·Conducting excessive office visits or writing excessive prescriptions 

·Prescribing more medications than necessary for treating a specific condition 

·Ordering excessive laboratory tests 

Abuse

Abuse includes practices that are inconsistent with professional standards of care; medical necessity; or fiscal, business, or medical practices; and that constitute an over utilization of Medicaid covered services and result in an unnecessary cost to the Medicaid program.  These can be actions that may directly or indirectly result in unnecessary costs.  Abuse involves paying for items or services when there is no legal entitlement to that payments, and the provider has not knowingly or intentionally misrepresented facts to obtain payment.

Examples of Medicaid Abuse

·Unknowingly billing for unnecessary medical services  

·Unknowingly billing for brand name drugs when generics are dispensed  

·Unknowingly excessively charging for services or supplies  

·Unknowingly misusing codes on a claim such as upcoding or unbundling codes  ​