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Medicare Compliance

Meridian Members

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. Healthcare fraud can take on many forms, from small infractions to multi-million dollar schemes. It can also occur anywhere, from small rural towns to major metropolitan cities.

How to Report Fraud

If you believe you have seen any of these activities, you can contact us immediately at 1-866-364-1350 (TTY: 711), Monday - Friday from 8 a.m. to 8 p.m. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. We will conduct a thorough investigation and work with State and Federal government agencies to make sure your rights and services are protected to the fullest extent. You may also visit our FWA Reporting Site at http://mhplan.ethicspoint.com.

Examples of Fraud

At MeridianCare, we are committed to doing our part to stop healthcare fraud. You can also do your part in fighting against healthcare fraud by protecting yourself against fraudulent claims and practices.

Here are some examples of activities you should look for:

  • Does your Explanation of Benefits (EOB) show a charge that you did not receive?
  • Does your provider bill for services not provided?
  • Is your provider rendering unnecessary services?
  • Is your provider prescribing a higher quantity than is medically necessary for a condition?
  • Did a sales agent call you or show up at your residence without your permission to market a Medicare Advantage product or service?
  • Did you get a phone call from an unknown caller offering low cost or free medical services? Did the caller ask for your personal information, such as your Social Security number, Medicare number or date of birth?
  • Do you know someone who changed or forged a prescription?
  • Do you know a provider who primarily writes for narcotics or controlled substances?
  • Do you know someone who visits multiple doctors to get the same prescription?
  • Do you know someone who fills a prescription and then sells the medication?
  • Are medications you picked up expired, fake or diluted?
  • Did you pharmacy give you generics when your prescription requires that a brand be dispensed?
  • Does your pharmacist provide less than the prescribed quantity and bill for the full amount?
  • Did you incur a claim for prescriptions that you never picked up?

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

Meridian 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 - Friday, 8 a.m. to 8 p.m. You may also visit our FWA Reporting Site at http://mhplan.ethicspoint.com.

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

Fecha de actualización: 10/01/24

H6080_WEBSITE_2025_Accepted_09302024


Fecha de actualización: 10/01/24

H6080_WEBSITE_2025_Accepted_09302024

Meridian Medicare-Medicaid Plan (MMP) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Meridian Member Handbook. For information on Meridian and other options for your health care, call the Illinois Client Enrollment Services at 1-877-912-8880 (TTY: 1-866-565-8576) or visit enrollhfs.illinois.gov. Out-of-network/non-contracted providers are under no obligation to treat Meridian members, except in emergency situations. Please call our Member Services number or see your Member Handbook for more information, including the cost-sharing that applies to out-of-network services. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al [1-855-580-1689] (los usuarios de TTY deben llamar al [711]). Los representantes están disponibles para ayudarle de [lunes a viernes de 8 a.m. a 8 p.m. Los fines de semana y los días feriados estatales o federales, es posible que se le solicite que deje un mensaje. Su llamada será devuelta dentro del siguiente día hábil]. La llamada es gratis. You can get this document for free in other formats, such as large print, braille, or audio. Call 1-855-580-1689 (TTY: 711). Representatives are available Monday-Friday, 8 a.m. to 8 p.m. to assist you. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.

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