Fraud, Waste, Abuse, and Mandatory Screening Information
Under the HealthChoices program, Keystone First receives state and federal funding for payment of services provided to our Members. In accepting Claims payment from Keystone First, Health Care Providers are receiving state and federal program funds, and are therefore subject to all applicable federal and/or state laws and regulations relating to this program. Violations of these laws and regulations may be considered fraud or abuse against the Medical Assistance program.
See the Medical Assistance Manual, Chapter 1101 or go to www.pacode.com/secure/data/055/partIIItoc.html for more information regarding fraud or abuse, including "Provider Prohibited Acts" that are specified in §1101.75. Providers are responsible to know and abide by all applicable state and federal regulations.
Keystone First is dedicated to detecting and preventing fraud and abuse from its programs and cooperates in fraud and abuse investigations conducted by state and/or federal agencies, including the Medicaid Fraud Control Unit of the Pennsylvania Attorney General's Office, the Federal Bureau of Investigation, the Drug Enforcement Administration, the HHS Office of Inspector General, as well as the Bureau of Program Integrity of DHS.
As part of Keystone First's responsibilities, the Payment Integrity department is responsible for identifying and recovering claims overpayments. The department performs several operational activities to detect and prevent fraudulent and/or abusive activities.
Examples of Provider Fraud include but are not limited to:
- Billing for services not rendered or not Medically Necessary*
- Submitting false information to obtain authorization to furnish services or items to Medicaid recipients
- Prescribing items or referring services which are not Medically Necessary
- Misrepresenting the services rendered
- Submitting a Claim for provider services on behalf of an individual that is unlicensed, or has been excluded from participation in the Medicare and Medicaid programs
- Retaining Medicaid funds that were improperly paid
- Billing Medicaid recipients for covered services
- Failure to perform services required under a capitated contractual arrangement
Examples of Recipient Fraud include but are not limited to:
- Member gets prescriptions filled at more than 2 pharmacy locations within one month.
- Member has prescriptions written by more than 2 physicians per month.
- Member fills prescriptions for more than 3 controlled substances per month.
- Member obtains refills (especially on controlled substances) before recommended days’ supply is exhausted.
- Duration of narcotic therapy is greater than 30 consecutive days without an appropriate diagnosis.
- Prescribed dose outside recommended therapeutic range.
- Same/Similar therapy prescribed by different prescribers.
- No match between therapeutic agent and specialty of prescriber.
- Fraudulent activities (forged/altered prescriptions or borrowed cards).
- Repetitive emergency room visits with little or no PCP intervention or follow-up.
- Same/Similar services or procedures in an outpatient setting within one year.
If the results of the review indicate recipient misuse, abuse or fraud, the Member will be placed on the Recipient Restriction Program, which means the Member(s) can be restricted to a single:
for a period of five (5) years.
Restriction to one Network Provider of a particular type will ensure coordination of care and provide for medical management.
Screening Employees for Federal Exclusion
As required by the Department of Health and Human Services’ Office of Inspector General (HHS-OIG) and outlined in the Pennsylvania Department of Human Services (DHS) Medical Assistance Bulletin 99-11-05*, all providers who participate in Medicare, Medicaid or any other federal health care program are required to screen their employees and contractors, both individuals and entities, to determine if they have been excluded from participation in any of the aforementioned programs.
All employees, vendors, contractors, service providers, and referral sources whose functions are a necessary component of providing items and services to MA recipients, and who are involved in generating a claim to bill for services, or are paid by Medicaid, should be screened for exclusion before employing and/or contracting with them and, if hired, should be rescreened on an ongoing monthly basis to capture exclusions and reinstatements that have occurred since the last search. Examples of individuals or entities that providers should screen for exclusion include, but are not limited to:
- Individual or entity who provides a service for which a claim is submitted to Medicaid;
- Individual or entity who causes a claim to be generated to Medicaid;
- Individual or entity whose income derives all, or in part, directly or indirectly, from Medicaid funds;
- Independent contractors if they are billing for Medicaid services;
- Referral sources, such as providers who send a Medicaid recipient to another provider for additional services or second opinion related to medical condition.
The Pennsylvania Department of Human Services and Keystone First are prohibited from paying for any items or services furnished, ordered, or prescribed by individuals or entities excluded from the Medical Assistance (MA) Program as well as other federal health care programs.
This payment ban applies to any items or services payable under a Medicaid program that are furnished by an excluded individual or entity, and extends to:
- All methods of reimbursement, whether payment results from itemized claims, cost reports, fee schedules, or a prospective payment system.
- Payment for administrative and management services not directly related to patient care, but that are a necessary component of providing items and services to Medicaid recipients, when those payments are reported on a cost report or are otherwise payable by the Medicaid program.
- Payment to cover an excluded individual's salary, expenses or fringe benefits, regardless of whether they provide direct patient care, when those payments are reported on a cost report or are otherwise payable by the Medicaid program.
Medicaid providers who employ or enter into contracts with excluded individuals or entities to provide items or services to Medicaid recipients when those individuals or entities are excluded from participation in any Medicare, Medicaid, or other federal health care programs are subject to termination of their enrollment in and exclusion from participation in the MA Program and all federal health care programs, recoupment of overpayments, and imposition of civil monetary penalties.
Reporting Fraud to Keystone First
If you, your employees or any entity with which you contract to provide health care services on behalf of Plan beneficiaries, become concerned about or identifies potential fraud, waste or abuse, please contact Keystone First by:
- Calling the toll-free MA Provider Compliance Hotline at 1-866-833-9718;
- E-mailing to email@example.com; or,
- Mailing a written statement to
Special Investigations Unit:
200 Stevens Drive
Philadelphia, PA, 19113
Below are examples of information that will assist Keystone First with an investigation:
- Contact Information (e.g. name of individual making the allegation, address, telephone number);
- Name and Identification Number of the Suspected Individual;
- Source of the Complaint (including the type of item or service involved in the allegation);
- Approximate Dollars Involved (if known);
- Place of Service;
- Description of the Alleged Fraudulent or Abuse Activities;
- Timeframe of the Allegation(s).
Reporting Fraud to the Commonwealth
Phone: 1-844-DHS-TIPS or 1-844-347-8477
Fax: 1-717-214-1200, Attn: OMAP Provider Compliance Hotline
Mail: Bureau of Program Integrity
OMAP Provider Compliance Hotline
P.O. Box 2675
Harrisburg, PA 17105-2675
Waste and Recovery
Examples of Waste include but are not limited to:
- Overpayment due to incorrect set-up or update of contract/fee schedules in the system.
- Overpayments due to claims paid based upon conflicting authorizations or duplicate payments.
- Overpayments resulting from incorrect revenue/procedure codes, retro TPL/Eligibility.
The Payment Integrity Department of Keystone First is responsible for identifying and recovering claim overpayments. The Department performs several operational activities to ensure the accuracy of providers’ billing submissions. The Department utilizes internal and external resources to prevent the payment of claims associated with waste and to initiate recovery when overpaid claims are identified.
As a result of these claims accuracy efforts, providers may receive letters from Keystone First, or on behalf of Keystone First, regarding recovery of potential overpayments and/or requesting medical records for review. Any questions should be referred to the contact information provided in the letter to expedite a response to questions or concerns.
Returning Improper or Over Payments
Contact Keystone First Provider Services Department at 1-800-521-6007 to arrange the repayment.
There are two ways to return overpayments to Keystone First:
- Have Keystone First deduct the overpayment/improper payment amount from future claims payments,
- Return the overpayments directly to Keystone First via:
- Using the Provider Claim Refund form (PDF).
- Mailing the completed form and refund check for the overpayment/improper payment amount to:
Claims Processing Department
P.O. Box 7115
London, KY 40742
Provider Self-Audit Protocol
Providers may also follow the Pennsylvania Medical Assistance (MA) Provider Self-audit Protocol to return improper payments or overpayments. Access the DHS voluntary protocol process via the following web address:
To search the List of Excluded Individuals/Entities (LEIE) database, please access: https://oig.hhs.gov/exclusions/index.asp
The Pennsylvania Department of Human Services’ Medicheck List of Precluded Providers may be accessed here: https://www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/Medicheck-List.aspx
Access the Electronic Code of Federal Regulations (42 CFR §455.436 ) here:
The System for Award Management (SAM) is an official website of the U.S. government.
For complete information, access The Department of Human Services Medical Assistance Bulletin #99-11-05.
*A service or benefit is Medically Necessary if it is compensable under the MA Program and if it meets any one of the following standards:
- The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.
- The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.
- The service or benefit will assist the Member to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the Member and those functional capacities that are appropriate for Members of the same age.
- Determination of medical necessity for covered care and services, whether made on a Prior Authorization, Concurrent Review, Retrospective, or exception basis, must be documented in writing.
- The determination is based on medical information provided by the Member, the Member's family/caretaker and the PCP, as well as any other practitioners, programs, and/or agencies that have evaluated the Member. All such determinations must be made by qualified and trained practitioners.