Compliance Information
Information on Compliance and Fraud, Waste, & Abuse
Medical Associates is committed to conducting our business with the highest possible standards of ethical behavior, displaying honesty and integrity throughout all interactions. Every Medical Associates employee, contractor or agent, regardless of their position, is expected to conduct themselves in a professional manner; free from the appearance of improper or unethical conduct.
Seven Elements of an Effective Compliance Program
Goal: Prevent, detect and correct noncompliance including fraud, waste & abuse.
- Implement Written Policies, Procedures and Standards of Conduct;
- Designate a Compliance Officer, Compliance Committee and High Level Oversight
- Conduct Effective Training and Education
- Develop Effective Lines of Communication
- Enforce Standards through Well Publicized Disciplinary Standards
- Conduct Internal Monitoring and Auditing and Identify Compliance Risks
- Detect Compliance Issues and Undertake a Prompt Corrective Action
What is Fraud, Waste, & Abuse?
Fraud is defined as the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes Fraud under applicable Federal or State law (42 CFR 455.2).
Abuse is defined as provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
Waste is defined as deficient practices, systems controls, or decisions that result in using, consuming, spending, or expending goods, services, or funds extravagantly, needlessly, thoughtlessly or carelessly.
Listed below are some general examples of potential Fraud, Waste and Abuse, but this list is not all inclusive:
- Falsifying Claims
- Falsifying Eligibility Determinations
- Misrepresentation of Member Eligibility
- Misrepresentation of Residency and/or Citizenship Status
- Falsifying Billing for Services
- Forgery or Alterations of Prescriptions
- Fraudulent Enrollment Practices
- Misrepresentation of Medical Condition
- Fraudulent Credentials
- Theft of Durable Medical Equipment
- Fraudulent Recoupment Practices
- Failure to Report Third Party Liability
- Embezzlement
How to Report Compliance Violations within Medical Associates Health Plans
To report suspected or actual compliance violations, such as fraud, waste, & abuse, HIPAA privacy and security violations, criminal activity, or illegal or unethical conduct occurring within Medical Associates Health Plans, please use one of the following methods.
Phone:
Toll Free: 800-747-8900, Option 5
Local: 563-584-4795
Callers may remain anonymous
Email:
MAHPComplianceHotline@mahealthcare.com
Mail:
Medical Associates Health Plan
1605 Associates Drive, Suite 101
Dubuque, IA 52002
Key MAHP Compliance Contacts
- Zach Keeling, Interim Compliance Officer
- Elizabeth Heying, Privacy Officer
- Jeremy Wulfekuhle, Security Officer
How to Report Insurance Fraud at the State Level
Iowa: https://iid.iowa.gov/reporting-insurance-fraud
Illinois: http://www.dph.illinois.gov/topics-services/health-care-regulation/complaints
Wisconsin: https://ociaccess.oci.wi.gov/complaints/public/
How to Report Fraud at the Federal Level
Contact: U.S. Department of Health and Human Services
Office of the Inspector General
- Email: HHSTips@oig.hhs.gov
- Mail:
Office of Inspector General
U.S. Department of Health & Human Services
ATTN: OIG HOTLINE OPERATIONS
PO Box 23489
Washington, DC 20026
- Phone: 800-447-8477
- Fax: 800-223-8164
How You Can Help
Take these steps to help protect yourself and others:
- Protect your health insurance card like you would a credit card. If your card is lost or stolen, contact Member Services immediately at 866-821-1365.
- Examine your Explanation of Benefits (EOB) forms to ensure that all the information is accurate and you have received the services listed.
- Report possible insurance fraud and abuse to Medical Associates or the appropriate state agency.
Help Prevent Fraud, Waste, & Abuse – Resources for Medicare Beneficiaries
Protecting Yourself & Medicare from Fraud
Help Fight Medicare Fraud
Identity Theft And Your Social Security Number
Beneficiary Card Sharing Education
What You Need To Know About Misleading Advertising
Helpful Documents
Compliance Program Description
Fraud, Waste, & Abuse Policy and Procedure
Code of Conduct
