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).
Fraud is defined as knowingly, intentionally, and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare 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 healthcare benefit program.
The most common fraudulent acts include, but are not limited to:
1. A provider 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