Compliance and Fraud, Waste and Abuse

Training for Providers

Providers that are contracted with Medica are required to complete general Compliance and Fraud, Waste and Abuse (FWA) awareness training. Training is required for employees, contractors and board members who provide health care services or administrative services for Medicare eligible individuals under the Medicare Advantage or Medica Part D programs. Training is also required of downstream and related entities that provide health care services or administrative services for Medicare and Medicaid eligible individuals.

Training must occur within 90 days of a provider's initial contract (or at time of hire) and annually thereafter.

All First Tier, Downstream and Related Entities (FDRs) have the option to offer their own compliance training. Centers for Medicare and Medicaid Services (CMS) also has available these web-based trainings: "Combating Medicare Parts C and D Fraud, Waste, and Abuse" and "Medicare Fraud & Abuse: Prevent, Detect, Report."

If you offer additional compliance training to your staff and downstream entities, you may not modify the CMS training content but you can add other topics specific to your organization's annual training program.

Medica communicates General Compliance and FWA training requirements to their FDRs, sub-contractors, and Qualified Health Plan (QHP) delegates within 90 days of the time of contract and annually thereafter. Additionally, Medica provides and communicates the Standards of Conduct and Reporting Policy, or you can choose to use your own entity's documentation.

• Medica Standards of Conduct - Business Partners (PDF)
• Medica Compliance Reporting, Investigation, and Prompt Response Policy (PDF)

Medicare Certified Providers

Providers that are Medicare-Certified are exempt from taking the Fraud, Waste and Abuse awareness training. However, providers are still required to complete Compliance and Fraud, Waste, and Abuse Training.

Retention Policy for Training Documentation

Your organization should keep a copy of all documentation related to the Compliance Program training and Fraud, Waste and Abuse awareness training for the required record retention period of 10 years.

Your record should include training dates, methods of training, training materials, and training logs identifying employees who received the training. Medica and our regulators, such as CMS, or agents of CMS may request these records to verify that training occurred.

Questions

If you have any questions or concerns, please call the Medica Provider Service Center at 1 (800) 458-5512.

Compliance Program

Standards of Conduct

We conduct business with the highest ethical standards, and our compliance program supports this. We've created the Medica Standards of Conduct to assist in understanding expectations for how we do business and to outline your responsibilities as a vendor that provides goods or services to Medica or our members.

As a Minnesota Department of Human Services (DHS) and a CMS contracted organization, we apply these Standards of Conduct to our first tier and downstream entities.

Medica Standards of Conduct – Business Partners (PDF)

Reporting Policy

Under our Compliance Program, providers, vendors, contractors and Medica employees are required to promptly report any good faith belief of any suspected or known violation of the laws and regulations that govern our business, our Standards of Conduct, financial reporting and standards, or our Corporate Compliance Program and Medicare Compliance Program, including our Privacy or Security Programs.

Medica Compliance Reporting, Investigation, and Prompt Response Policy(PDF)

Special Investigations Unit (SIU)

Medica's SIU investigates allegations of fraud and abuse on behalf of Medica and its clients, and conducts proactive provider audits and claim analysis to identify suspicious billing patterns. The mission of the SIU is to prevent, detect, investigate, report, and when appropriate, recover money upon confirming fraud, waste, abuse, or error. These actions help ensure that member premium dollars are spent for legitimate health care purposes.

The SIU is authorized to conduct investigations to ensure compliance with Medica requirements by monitoring the use of health services by members and the delivery of health services by providers. Network providers should notify Medica's SIU of any incident where provider billing fraud or abuse may have occurred, or where members have engaged in fraudulent or abusive activity.

Examples of fraud include:

• Billing for a medical service or equipment that was not provided
• Upcoding for expensive, medically unwarranted services
• Prescribing unnecessary medications to patients
• Using another person's ID card to obtain medical services

Credible Allegation of Fraud

Medica may suspend payments to a provider for a credible allegation of fraud if Medica determines there is a credible allegation of fraud against the provider for which an investigation is pending including an investigation by Medica or law enforcement; or a government agency has notified Medica that it has suspended all payments based on a determination there is a credible allegation of fraud against the provider for which an investigation of payments is pending. The suspension of payments of claims due to a credible allegation of fraud may:

• Be based on a credible allegation of fraud either related or unrelated to health care
• Apply across all lines of Medica business

"Credible allegation of fraud" means an allegation from any source which has the indicia of reliability. Sources of a credible allegation of fraud include but are not limited to:

• Integrity line complaints
• Claims data mining
• Patterns identified through provider audits, civil false claims cases, and investigations by Medica's SIU or law enforcement

Medica may exercise a good cause exception to:

• Not suspend payments
• Delay suspension of payments
• Cease continuation of payment suspension
• Suspend payments only in part

Medica may find that a good cause exception exists in certain circumstances, such as the need to delay suspension of payments until there is transition of Medica members to another appropriate provider to ensure member health and safety.

A provider's participation agreement with Medica may be terminated by Medica based upon the findings of an investigation by a government agency or Medica.

Restricted Recipient Program

The Minnesota Restricted Recipient Program identifies suspected cases of abuse of health services or prescription drugs by members.

Components

The program follows the standards set in Minnesota Rules.

All restricted recipients have designated providers that must provide all services, including a primary care provider, at one clinic location, a hospital (including emergency room) and pharmacy (at one location).

The designated primary care provider manages referrals to non-designated providers (specialists).

Criteria Used to Identify Candidates

Members receiving prescriptions for controlled substances (Schedule I through V) from multiple prescribers.

Members repeatedly utilizing emergency department or urgent care services for non-emergency services.

Members obtaining overlapping controlled substance prescriptions from one or more prescribers.

Minnesota Health Care Programs (MHCP) members who have abused health care services as described in the Minnesota Rules Part 9505.2165.

In addition, MHCP members can be restricted by DHS or previous health plans. MHCP members under restriction who change plans remain under restriction with the new MHCP plan until they have satisfied the time period of the restriction and meet criteria for discharge.

Program Management

After a member is identified as a potential candidate for program enrollment, medical and pharmacy claim histories are reviewed. Members with appropriate medical explanations for their aberrant claims activity are excluded from program enrollment.

A letter is sent to the members meeting enrollment criteria notifying them of their enrollment in the program, contact information to Medica’s Restricted Recipient Program staff and their appeal rights.

Members are initially enrolled for 24 months of eligibility. After 22 months, claims are reviewed again and if the member was compliant with the program, they are removed on their end date. If the member did not follow the rules of the program, they are re-enrolled for an additional 36 months of eligibility.

While the member is enrolled in the program, the Nurse Investigator is the contact person for member and/or provider concerns or questions.

Designated Primary Care Provider Involvement

The designated primary care provider (PCP) is notified by letter that they have been assigned as the member's designated PCP, along with information about the program and the Medica Restricted Recipient Program staff contact information.

The designated PCP is responsible for coordinating all care and services for the member.

The designated PCP authorizes controlled substance prescriptions for the member, either directly or by referral authorization.

The designated PCP reviews the necessity of care from non-designated providers and authorizes referrals as needed. See Medica referral guidelines for the Restricted Recipient Program. If a patient needs ongoing care from a specialist, the PCP should consider a standing referral or contact the nurse investigator to discuss arranging to have the specialist added as an authorized provider.

Other Providers

All providers servicing MHCP recipients should check MN-ITS before providing care. If an enrollee is restricted, your claim will not be paid unless you have received a referral from the member's designated primary care provider. For more information, call Medica's Restricted Recipient Program toll-free at 1 (888) 906-0970.

Report Fraud or Abuse

The Medica Reporting Policy applies to Medica providers, vendors and contractors, and Medica employees. There are multiple ways to report suspected fraud or abuse committed against Medica depending on the situation and how you are most comfortable reporting the issue.

You can report suspected fraud or abuse online to our SIU or by calling the hotline number below.

Special Investigations Unit Referral Form

REV 12/2023