Report Fraud, Waste, and Abuse

MedStar Family Choice and MedStar Health have comprehensive Compliance programs in place to monitor and detect fraud, waste, and abuse. Fraud, waste, and abuse could be committed by a provider, member, or even an employee of the MCO. As a MedStar Family Choice provider, it is your responsibility to report fraud and abuse.

Medicaid defines fraud as an intentional deception made by a person or company with the intent to gain some unauthorized benefit from the deception. Waste means over-utilization of services, or practices that result in unnecessary costs. Abuse includes practices that do not follow sound financial, business or medical practice and result in unnecessary costs or do not meet a standard of care. Some common examples of fraud, waste, and abuse are:

  • Billing for a service that was never performed
  • Billing for services that were actually performed by another provider
  • Billing for non-covered services using incorrect CPT, HCPCS and/or Diagnosis code to receive payment
  • Unbundling of procedures
  • Upcoding
  • Modifier misuse
  • Lack of documentation in the medical record to support the services billed
  • Performing unnecessary procedures
  • Altering or forging a prescription
  • Allowing others to use a member's ID card for care

Most billing errors are oversights and not indicators of fraudulent activity. However, fraud and abuse does occur and the Maryland Department of Health (MDH) has tasked MedStar Family Choice with monitoring, identifying, and deterring these types of activities. As a result, MedStar Family Choice regularly monitors and audits claims submissions and encounter data. In addition, we perform routine and random chart audits as a part of our Compliance Program. At some point, your office may be asked to comply with one of our chart audits. MDH expects MedStar Family Choice to report fraud and abuse. MDH or the Medicaid Fraud Control Unit may perform its own investigation. Penalties such as fines, loss of licensure or imprisonment can occur for providers found guilty of fraudulent activity.

In addition to the Compliance Program described above, it is important that our providers understand the False Claims Act provisions for Federal and state governments. Under the Deficit Reduction Act of 2005, entities receiving $5 million or more in Medicaid funding must educate employees, contractors and agents about Federal and State fraud and false claims laws, as well as whistle blower protections. Find out more information regarding these laws and protections by clicking here.

While MedStar Family Choice monitors for possible fraud, waste, and abuse activities, we need your help to identify and report potential issues. If you know of a situation that may involve fraud and abuse please report it immediately by calling the MedStar Family Choice Compliance Director at 410-933-2283. You may also contact Provider Relations at 410-933-3069, or you may also call the Medstar Health Corporate Integrity Hotline at 877-811-3411. You may remain anonymous and all reports will be kept confidential. In addition, MedStar Family Choice enforces a non-retaliation policy for those individuals reporting possible fraud, waste, and abuse.

Information current as of: 12/03/21