Fraud, Waste, and Abuse
Addressing Fraud, Waste, and Abuse
As part of our efforts to improve the healthcare system, APA ACO has made a commitment to detecting, correcting, and preventing fraud, waste, and abuse.
Success in this effort is essential to maintaining a healthcare system that is affordable for everyone. APA ACO is undertaking a campaign to get the word out about how contracted physicians, other health care providers, and business partners can help with fraud, waste, and abuse detection, correction, and prevention.
What are Fraud, Waste, and Abuse?
Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)
Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Abuse Payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.
Fraud, Waste and Abuse Training and General Compliance Training
APA ACO has adopted training content published by the Centers for Medicare & Medicaid Services (CMS) that addresses this subject matter. For purposes of the relationships that contracted health care providers and business partners* have with APA ACO, this training, including all references and requirements related to Medicare.
Contracted health care providers and business partners supporting APA ACO’s Medicare product, must use CMS content to train their employees and the entities supporting them to meet certain contractual obligations to APA ACO.
* CMS designates these as first tier, downstream, or related entities (FDRs).
Accessing the CMS Training Material
- Navigate to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
- Scroll to the “Fraud and Abuse-related Resources” section
- Click on “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training”
- Follow the instructions within the CMS document
Additional Compliance Program Requirements for FDRs
Additional compliance program requirements for FDRs supporting APA ACO’s Medicare product are outlined in, but not limited to the documents listed in subsequent sections of this page.
Standards of Conduct
Here we have posted our Ethics Every Day for Contracted Health Care Providers and Business Partners, which is closely aligned with APA ACO’s standards of conduct for its employees. We invite contracted health care providers and business partners to review this information as soon as possible.
Ethics Every Day for Contracted Health Care Providers and Business Partners
This policy communicates APA ACO’s strong and explicit organizational commitment to conducting business ethically, with integrity and in compliance with applicable laws, regulations and requirements. APA ACO requires its contracted health care providers and business partners to uphold a similar commitment to ethical conduct and assure that they, their employees, and downstream entities who support APA ACO comply with the guiding principles outlined in this policy.
Compliance Policy for Contracted Health Care Providers and Business Partners
How to Report Fraud, Waste, and Abuse
If you suspect fraud, waste, or abuse in the healthcare system, you must report it to APA ACO and we’ll investigate. Your actions may help to improve the healthcare system and reduce costs for our members, customers, and business partners.
To report suspected fraud, waste, or abuse, you can contact APA ACO in one of these ways:
- Phone: English 1-888-706-0581
- Fax: 1-818-484-2517
- E-mail: ACOethicshotline@apollomed.net
- Mail: APA ACO, Special Investigation Unit, 700 N. Brand Blvd. Ste. 1400, Glendale, CA 91203
You may remain anonymous if you prefer. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, APA ACO corporate law department, market medical directors or APA ACO senior management).
Special Investigation Unit (SIU) Tools and Resources
APA ACO’s Special Investigation Unit (SIU) utilizes software tools that help find and prevent health care fraud. This fraud detection software also allows us to review our claims for possible fraud before payment.
SIU references the following resources to support its investigations:
- Medical and Pharmacy Coverage Policies
- Medicare Coverage Database – Centers for Medicare & Medicaid Services National Coverage Determination (NCD) and Local Coverage Determination (LCD)
- American Medical Association (AMA) Current Procedural Terminology (CPT®), International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) and Healthcare Common Procedure Coding System (HCPCS) coding references
What We Do
Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:
- Contact with relevant parties to gather information. This may include contacting members to get a better understanding of the situation. For example, we may contact a member to ask about a visit with his or her physician. We may ask the member to describe the services provided, who provided the care, how long the member was at the office, etc.
- Requests for medical records. We do this to validate that the records support the medical services billed. It’s important that the health care provider submits complete records as requested. We rely on this information to make a fair and appropriate decision.
- Notification of suspected fraud and abuse to law enforcement and CMS, if applicable, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare part C (medical) and part D (prescriptions) and any other applicable state and/or federal agencies.
Most Common Coding and Billing Issues
Some of the most common coding and billing issues are:
- Billing for services not rendered
- Billing for services at a frequency that indicates the provider is an outlier as compared with their peers.
- Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
- Billing for services that are actually performed by another provider
- Modifier misuse, for example modifiers 25 and 59
- Billing for more units than rendered
- Lack of documentation in the records to support the services billed
- Services performed by an unlicensed provider but billed under a licensed providers name
- Alteration of records to get services covered