November 28, 2023
Help prevent fraud, waste and abuse by reporting it
Health care fraud contributes to the rising cost of health insurance and reduces the amount of funds available to pay honest providers. Wellcare investigates allegations of fraud, waste and abuse (FWA) and reports of noncompliance at every level.
Physicians and other providers must comply with federal and state false claims laws.
Definitions
- California False Claims Act (CA GOV § 12650-12565): State legislation which allows the Attorney General to bring a civil law enforcement action to recover damages and civil penalties against any person who knowingly makes or uses a false statement or document to obtain money or property from the state. It permits whistleblowers to file a civil law action on behalf of the government as a “qui tam relator.”
- Federal False Claims Act (31 U.S.C. § 3729): Federal legislation which allows the government recourse against any person who knowingly presents a false or fraudulent claim for payment or approval; knowingly makes a false or fraudulent claim to be paid or approved by the government; conspires to defraud the government by getting a false or fraudulent claim paid or approved by the government; or knowingly makes a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.
Delegated IPA responsibility
The Plan requires delegated independent practice associations (IPAs) to comply with the federal FCA, federal Anti-Kickback Statute, Program Fraud Civil Remedies, and Deficit Reduction Act of 2005 in the delivery of services to the Plan’s members. Delegated IPAs must implement and maintain written policies for all employees and subcontractors that provide detailed information about the FCA and other state and federal laws as described in the Deficit Reduction Act, including information about rights of employees to be protected as whistleblowers.
How to report FWA
If you obtain information that reasonably leads you to believe there has or may have been a violation of law or of the Plan’s Compliance program, you must promptly report and disclose your concerns to the Plan’s Compliance Department. You also must cooperate with the Compliance Department in any audit or investigation implemented by the Plan due to your report. The Plan prohibits any form of retaliatory conduct or action against any employee or person who reports any compliance violation or concern.
- Compliance Department hotline
- Use the following phone number to report concerns to the Plan’s Compliance Department. A report may be made anonymously. All reports to the Compliance Department are treated as confidential to the greatest extent possible.
- FWA hotline: 1-866-685-8664
False claim laws
State and federal false claims laws combat fraud and abuse in governmental health care programs including Medicare and Medicaid.
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The federal FCA provides that any person who (1) knowingly presents, or causes to be presented, to an officer or employee of the United States government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval; (2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the government; (3) conspires to defraud the government by getting a false or fraudulent claim paid or approved by the government;... or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government, is liable to the United States government for a civil penalty [as specified] 31 U.S.C. § 3729.
The FCA imposes liability on any person who submits a claim to the federal government or to the state Medicaid program (including the Plan) when the person knows (or should know) the claim is false. It also imposes liability on an individual who may knowingly submit a false record to obtain payment from the government. - The California FCA provides that private parties may bring an action on behalf of the government to recover the funds paid by state health programs as a result of false claims. These private parties (qui tam relators) are protected from retaliation by their employer under whistleblower protections. These provisions apply to any employee who is discharged, demoted, suspended, threatened, harassed or in any other way discriminated by their employer in the terms and conditions of employment as a result of the employee’s lawful acts in furtherance of a false claims action.
Additional information
Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online at wellcare.com/California/Providers/Medicare.
If you have questions regarding the information contained in this update, contact 1-866‑999‑3945.
This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers.
