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Combating Fraud, Waste and Abuse

Commonwealth Care Alliance, Inc. (CCA) is committed to conducting its business operations in compliance with ethical standards, internal policies and procedures, contractual obligations and all applicable federal and state statutes, regulations and rules, including but not limited to, those pertaining to the Centers for Medicare and Medicaid Services (CMS) Part C and D programs; the Massachusetts Executive Office of Health and Human Services (EOHHS), (MassHealth) and the Office of Inspector General (OIG).

  • What is health care fraud?

    Fraud is defined as knowingly, intentionally 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 money or property owned by or under the custody or control of any health care benefit program.

    The most common fraudulent acts include, but are not limited to:

     

    1. Aprovider billing for services, procedures and/or supplies that were never provided or performed
    2. A member knowingly sharing their CCA ID card with a non-CCA member in order to obtain services
    3. Intentionally misrepresenting any of the following, for purposes of obtaining a payment-or a greater payment-to which one is not entitled*:
      • The nature of services, procedures and/or supplies provided or performed;
      • The dates on which services and/or treatments were rendered;
      • The medical record of service and/or treatment provided;
      • The condition treated or the diagnosis made;
      • The charges for services, procedures and/or supplies provided or performed;
    4. The identity of the provider or the recipient of services, procedures and/or supplies.
    5. The deliberate performance of medically unnecessary services for the purpose of financial gain.*

     

    *Source: NHCAA Consumer Action and Information

  • Fraud Awareness

    Offers of "free" medical treatments or consultations often sound appealing and legitimate. They may come in advertising, a telephone solicitation, even at your front door.

    Be careful. Sometimes they are a lure used by scam artists to obtain your patient identification and insurance information to commit health insurance fraud. How can you stop it?

    Read your policy and any paperwork you receive from CCA. Make sure you actually received the treatments for which your insurance was charged, and question suspicious expenses.

    Beware of "free" offers

    Offers of "free" services are often fraud schemes designed to bill you and your insurance company illegally for thousands of dollars of treatments you never received. Protect your health insurance card like your credit card. In the wrong hands, a health insurance card is a license to steal. Don't give policy numbers or other identifying information to telephone solicitors.

    Tips

    Never give out Medicare, Social Security, bank account or credit card numbers to a person who calls on the phone. Hang up the phone. No Medicare drug plan can ask a person for that information on the phone. No drug plan representative can come into your home uninvited, without an appointment.  


    *Source: NHCAA Consumer Action and Information

Report Suspected Fraud and/or Compliance Concerns

If you or a family member or caregiver suspect compliance concerns such as potential fraud or abuse, you can contact CCA without fear of retaliation or retribution for reports made in good faith:

Report to CCA’s Compliance Hotline 800-826-6762

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