Health Care Fraud

Johns Hopkins HealthCare (JHHC) wants to find and stop healthcare fraud.  On average, healthcare fraud accounts for 10 percent of our nation’s annual healthcare expenditure.  An estimated $68 billion is lost annually due to healthcare fraud.  While most claims payment errors are just the result of mere oversights, there continues to be a small number of healthcare providers who intentionally engage in conduct intended to commit fraud.

Healthcare fraud is defined as any deliberate and dishonest act committed with the knowledge that it     could result in an unauthorized benefit to the person committing the act or someone else who is similarly    not entitled to the benefit.  Examples of healthcare fraud are:

• Misrepresentation of the type or level of service provided;
• Misrepresentation of the individual rendering service;
• Billing for items and services that have not been rendered;
• Billing for services that have not been properly documented;
• Billing for items and services that are not medically necessary;

Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);
Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (upcoding);

How Can I Help as a Provider?

• Validate all member ID cards prior to rendering service;
• Ensure accuracy when submitting bills or claims for services rendered;
• Submit appropriate Referral and Treatment forms
• Avoid unnecessary drug prescription and/or medical treatment;
• Report lost or stolen ID cards; and
• Report all suspicions of fraud by contacting one of the following appropriate JHHC lines of business: Priority Partners, Employer Health Plan, or US Family Health Plan or:

Call:  410-424-4996 or call 1-800-654-9728 and ask for the Compliance Department
Write:  JHHC Compliance Department, 6704 Curtis Ct, Glen Burnie, MD 21060
Email:  Compliance@jhhc.com
Fax:  410-424-4996

What happens to me if I report a concern?

Johns Hopkins HealthCare takes its responsibility to protect your ‘right to report’ seriously!  No Health Plan employee may threaten, coerce, harass, retaliate, or discriminate against any individual who reports a compliance concern.  To support this effort, the Health Plan has enacted zero-tolerance policies and annually trains all personnel on their obligation to uphold the highest integrity when handling compliance related matters. Any individual who reports a compliance concern has the ‘right’ to remain nameless and JHHC commits to enforcing this ‘right!’

In an effort to deter these and other instances of fraud, the JHHC Corporate Compliance Department routinely performs validation audits on statistical samples of claims.  As a result of the recent expansion of the JHHC Corporate Compliance Department, plans are underway to broaden those audits to include encounter and utilization data assessments. 

In addition, the JHHC Corporate Compliance Department investigates all detected outliers and other deviations from standard practice as well as all allegations of healthcare fraud it receives from recipients and others and reports substantiated allegations to the appropriate regulatory authorities who may, in turn, perform its own fraud investigation and take action against those who are found to have committed fraud.