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School of Medicine
Health Care Fraud and Abuse
Johns Hopkins HealthCare (JHHC) wants to find and stop health care fraud and abuse. It is estimated that billions of dollars are lost annually due to health care fraud and abuse. JHHC takes its responsibility seriously to protect the integrity of the care its members receive, its Health Plans, and the Federal and State Programs it administers.
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 (up-coding).
Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
- Misusing codes on a claim;
- Charging excessively for services or supplies; and
- Billing for services that were not medically necessary.
Both fraud and abuse can expose a provider or vendor to criminal and civil liability.
How Can I Help Prevent Fraud and Abuse?
- 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 prescription pads and/or fraudulent prescriptions; and
- Report all suspicions of fraud by contacting one of the following appropriate JHHC lines of business: Priority Partners, Employer Health Programs, or Johns Hopkins US Family Health Plan or:
- Call: 410-424-4996 or contact your JHHC Provider Relations representative who will forward your inquiry to the Corporate Compliance Department
- Write: JHHC Corporate Compliance Department, 6704 Curtis Court, Glen Burnie, MD 21060
- Email: Compliance@jhhc.com
- Fax: 410-762-1527
What should you do if you suspect or have knowledge of fraud and abuse?
All JHHC providers, subcontractors and vendors are required to report concerns about actual, potential or perceived misconduct to the JHHC Corporate Compliance Department at the numbers/addresses noted above.
What happens to me if I report a concern?
JHHC takes its responsibility to protect your reporting of actual or suspected fraud and abuse seriously. No employee may threaten, coerce, harass, retaliate, or discriminate against any individual who reports a compliance concern. To support this effort, JHHC 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 anonymous and JHHC commits to enforcing this right. In an effort to deter these and other instances of fraud and abuse, the JHHC Corporate Compliance Department routinely performs validation audits of claims and medical record documentation.
In addition, the JHHC Corporate Compliance Department investigates all detected outliers and other deviations from standard practice as well as all allegations of health care fraud and abuse that it receives from recipients and others. The Corporate Compliance Department reports substantiated allegations to the appropriate regulatory authorities who may, in turn, perform its own fraud and/or abuse investigation and take action against those who are found to have committed health care fraud and/or abuse.
For further information, read our Fraud/Abuse and False Claims Act Compliance Educations for Provider, Contractors, and Vendors.