Report Fraud
With your help we can avoid fraud, waste and abuse of medical services.
With your help we can avoid the medical fraud that affects the health care industry, the entities that offer their services, and you as a beneficiary. Herein, we’ll teach you how to recognize, differentiate, and prevent fraud, waste, and abuse.
Fraud
A false representation to obtain unauthorized benefit or profit. It is a scam, and even though the person knows is not correct, does it.
Waste
Occurs when someone incurs in unnecessary, extravagant, or negligent costs, or resources are poorly managed. Usually waste is a result of poor decisions and poor controls.
Abuse
When a provider is inconsistent with good practices in medicine, businessor physically. Results in a cost, or in reimbursements for services that are not medically necessary or do not comply with the professional and ethical standards of the health industry.
Examples of fraud, waste or abuse:
Billing of Services Not Rendered
This may include billing for services not performed, billing for a higher level of services than the ones performed, billing using inflated procedure codes and overstating patient diagnoses.
Alterations in claim forms and clinical records.
Billing of providers excluded from participation in federal programs.
Billing for non-prescribed / non-dispensed medications.
Altering prescriptions (drugs, quantities).
Anti-Kickback –When remuneration is solicited, received,or paid in exchange for referrals to provide services that are reimbursable by the federal government.
Stark Law –Provider refers a Medicare enrollee to receive some services in a business in which he/she or a family member has financial interests.
Beneficiary Inducement Law –Remuneration is offered to influence a beneficiary in choosing a particular provider or supplier.
Beneficiary Prescription Abuse -A patient obtains controlled substances by stating a false medical condition. Typically, patients will visit multiple physicians with the same complaint to obtain multiple prescriptions and fill those prescriptions at multiple pharmacies. This allows the patient to illegally obtain narcotics or other controlled substances for personal use or sale.
Conflict of Interest -An employee, manager, or executive has an undisclosed economic or personal interest in a transaction. For example, an employee steers a contract to a company the employee or a family member owns, without disclosing the relationship.
What can you do if you suspect or are aware of fraudulent or abusive behavior?
Here are several options:
Call our hotline at:
1-877-307-1211
Send us a fax to:
787-999-1725
Send us an email:
siu@mmmhc.com
Write us at:
MMM Healthcare, LLC
Departamento de Cumplimiento
Torre Chardón
350 Ave. Chardón, Suite 500
San Juan, PR 00918-2101
You may remain anonymous if you wish. All information received will be treated as confidential and the results of investigations will be addressed only by persons who have legitimate grounds for receiving the information (e.g., state and federal authorities, and directors of MMM Healthcare, LLC).
Report ethical, compliance, fraud, waste and abuse violations, in a confidential manner by accessing here or calling at 1-877-307-1211