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Medicare Compliance

MeridianComplete Providers, Vendors, Business Partners, or Sales Agents

Each year, healthcare fraud costs taxpayers billions of dollars. It drives up the cost of health care and puts a burden on taxpayers and the healthcare system. As an entity that does business with MeridianCare, you have a duty to prevent, detect and correct noncompliance and fraud, waste and abuse (FWA).

Reporting

If you suspect noncompliance or FWA activities, you must report them to your MeridianCare contract administrator. You may also report anonymously 24/7 at 1-866-364-1350 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m. You may also visit our FWA Reporting Site.

Examples of Noncompliance and FWA

Here are some common examples of noncompliant and FWA activities:

Providers & Pharmacies:

  • Submitting claims when you are on the Office of Inspector General's (OIG) exclusion list
  • Billing multiple payers for the same service, except as required for coordination of benefit
  • Inappropriate up-coding
  • Billing for services not rendered
  • Providing excessive or unnecessary services
  • Prescription forging or altering
  • Receiving illegal payments or other benefits to prescribe certain medications
  • Prescription drug shorting
  • Providing false or misleading information to justify coverage
  • Dispensing expired or adulterated prescription drugs
  • Illegal distribution of free samples
  • Billing for non-covered services as covered
  • Stolen prescriber Drug Enforcement Agency (DEA) number or prescription pad
  • Not meeting your contractual performance standards
  • Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule

Sales Agents:

  • Using marketing materials not approved by MeridianCare or the Centers for Medicare and Medicaid (CMS)
  • Using high pressure sale tactics
  • Using deceptive and misleading sale tactics
  • Selling or marketing when you are not licensed or appointed
  • Making unsolicited contacts with beneficiaries
  • Not meeting your contractual performance standards
  • Inappropriate disclosure or violation of the HIPAA Privacy and Security Rule

Administrative Business Partners:

  • Doing Medicare work when you are on the Office of Inspector General's (OIG) exclusion list
  • Not meeting your contractual performance standards
  • Not providing annual compliance and FWA training to your employees
  • Not overseeing the work of your subcontractors

Compliance and FWA Training

You and your employees are required to take the training annually. For your convenience, we have provided you with the following training materials.

You must ensure that all of your employees and any downstream entity (i.e., subcontractor) take this CMS-approved training module annually and read our Compliance Program & Standards of Conduct. All new employees and any downstream entity (i.e., subcontractor) must complete this as part of their orientation within 90 days of hire. Please document and retain proof of completion. You must use the Training Attendance Log (PDF) to track your completion.

If your employees have taken compliance training for other Medicare Advantage plans (through similar CMS-approved training modules) or through CMS' Medicare Learning Network (MLN) website, you do not have to re-take this training. However, you must still be familiar with our Compliance Program & Standards of Conduct, since they pertain to our company specifically. Also, if you are a medical provider and have met the most recent fraud, waste and abuse (FWA) certification requirements through enrollment into the Original Medicare program, as required by Medicare, you do not have to take Module I. FWA Training. However, they must still document their completion using the other health plan's Training Attendance Log or a modified version thereof. You do not need to send anything to us. However, your proof of training attendance and completion will be subject to audit and verification.

Resources

There are many resources available to help you stay informed of fraudulent activities and give you tips on how to protect yourself from them. This is just a short list of some of these resources.

Privacy Practices

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