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Health Care Fraud and Abuse
Fraud is the intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right. It is estimated that nearly 60 billion dollars are lost annually due to health care fraud and abuse. JHHC takes is dedicated to protect the integrity of the care its members receive, its Health Plans, and the Federal and State Programs it administers.
The mission of the Special Investigations Unit (SIU) is to identify and stop instances of fraud. With decades of experience in fraud investigations, members of this unit are uniquely equipped for this role. We are asking for YOU to join us by taking an active role in the fight against fraud.
The following are examples of healthcare fraud which you may encounter and should report:
- 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 would be 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 the JHHC Special Investigations Unit at:
- Phone: 410-424-4971
- Toll-free: 1-844-697-4071 (TTY: 711)
- Fax: 410-424-2708
- Email: FWA@jhhc.com
- By Mail: Payment Integrity Department,
- Attention: Special Investigations Unit, 7231 Parkway Drive, Suite 100, Hanover, MD 21076
For all compliance concerns, you can also contact our 24/7 SPEAK2US HOTLINE at
- Call: 1-844-SPEAK2US (1-844-773-2528)
- Website: JohnsHopkinsSpeak2Us.com
All JHHC and Medicare Compliance referrals/reports are treated confidentially and may be made anonymously.
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 and Medicare Compliance Departments investigate 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 Special Investigations Unit reports all 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.