Fight Fraud

Our Compliance Team is on the Case

To combat and prevent fraud before it happens, we have set up a Corporate Compliance and Integrity Program to monitor and verify internal procedures with all laws and regulations. Our Special Investigations Unit (SIU) detects and investigates health care fraud by reviewing computer records and working with law enforcement agencies to uncover criminal activity.

Your Information is Safe with Us

In addition to our external program, we’ve take additional steps to safeguard your personal information. Our internal compliance program ensures that all CDPHP employees uphold their legal and ethical duties to members, practitioners, employers, brokers and the company as a whole.

What Does Corporate Compliance Misconduct Include?

Members

• Your health records were accessed without your authorization
• You were given false or misleading information about a product
• Your information was altered without your permission

Providers

• Your claim submissions were inappropriately altered
• A patient’s health information was compromised
• An employer group is involved in the submission of false claims

Employers

• You were provided with false or misleading information about a product
• You suspect an inappropriate enrollment practice (i.e. falsifying an enrollment application)
• Your employee’s privacy rights were violated

Brokers

• A member’s privacy rights were violated
• You suspect an inappropriate enrollment practice (i.e. falsifying an enrollment application)
• You were advised to use false or misleading information to sell a product

We Want To Hear From You

If you know of suspect that fraud is taking place, please call the CDPHP corporate compliance officer at (518) 641-5260, or call the CDPHP Fraud hotline at 1-800-280-6885.

Download a copy of the CDPHP Corporate Compliance Policy.

The Don’ts that Make a Difference

Everyone can take steps to prevent committing and falling victim to fraud by following these simple guidelines.

Member Don’ts:

• Using your prescription coverage to get medications for others who are not insured or for your pets.
• Loaning your card or using someone else’s health insurance card to get treatment.
• Keeping or adding a divorced spouse on your policy.
• Falsifying your earned income on your application to get reduced premiums or obtain government-subsidized coverage such as Medicaid, Child Health Plus, or Family Health Plus.
• Selling or trading your prescription drugs or supplies.
• Filling claims when treatment or prescriptions were never received.
• Forging or altering a prescription to obtain drugs, services, or supplies.

Provider Don’ts:

• Possession of more than one active member ID card.
• Billing for services not rendered.
• Billing for higher level of service than what was provided.
• Billing with codes that were not related to the visit to get coverage.
• Billing a non-covered service as a covered service.
• Prescribing additional and unnecessary treatments (overutilization).
• Billing for different service site to increase revenue.

Broker Don’ts:

• Altering documents to meet eligibility requirements.
• Bribery and kickbacks.
• Sales of non-existent policies.
• Listing individuals who are not part of the group enrollment to get a better premium.
• Falsifying or using misleading information to sell a product.
• Failing to disclose information that may affect conditions of coverage.

Employer Don’ts:

• Providing false employer or group membership information to secure health care coverage.
• Misrepresenting who is actually eligible for coverage by falsely including a non-employee as an employee of the group.

Rescission of Member Eligibility

• CDPHP may rescind a members eligibility only under specific circumstances as defined by the Affordable Care Act.
• The provisions of the Federal Affordable Care Act (ACA) prohibit health carriers from rescinding policies unless a rescission is based upon fraud or intentional misrepresentation of material fact. A rescission is a cancellation or discontinuance of coverage that has a retroactive effect. A cancellation or discontinuance of coverage is not a rescission if:
• (i) The cancellation or discontinuance of coverage has only a prospective effect; or
• (ii) The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.

What is the Federal False Claims Act (FCA)?

The Federal False Claims Act (FCA) establishes liability for those making knowingly false or fraudulent claims against federally funded programs including Medicare and Medicaid, as well as those who knowingly make or use a false record or statement material to a fraudulent claim.

Violators of the FCA are subject to civil penalties for each false claim and related damages. Providers or suppliers who have been convicted of a violation may be excluded from participation in federal health programs.

Under the Federal False Claims Act, anyone who has direct information about an alleged false claim submitted to the government may file a lawsuit on behalf of the government in federal district court. The FCA provides protections to those who report a false claim.

New York State (NYS) False Claims Act
New York also imposes penalties and fines on those who submit false or fraudulent claims for payment to state or local governments under programs such as Medicaid. The penalty for filing a false claim in $6,000 to $12,000 per claim, in addition to related damages.

The NYS False Claims Act also provides protection to whistleblowers facing retaliation at work as a result of an action filed under the NYS False Claims Act. To learn more, a summary of Federal and New York statutes related to false claims is provided for your reference.