Program Integrity


Compliance / Fraud and Abuse

Thurston-Mason Behavioral Health Organization (TMBHO) adheres to the definitions and principles established by the Centers for Medicare and Medicaid Services (CMS).

Fraud

We define fraud as an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person. The violator may be a practitioner, provider employee or beneficiary.

Examples of fraud include, but are not limited to the following:

  • Billing for services or supplies that weren’t provided;
  • Altering claims to obtain higher payments;
  • Soliciting, offering, or receiving a kickback, bribe, or rebate (example: paying for referral of clients);
  • Provider completing Certificates of Medical Necessity (CME) for patients not known to the provider;
  • Suppliers completing CMEs for the physician;
  • Using another person’s Medicaid card to obtain medical care.

Waste

Waste as described by CMS is generally understood to encompass overutilization, underutilization or misuse of resources, and typically is not a criminal or intentional act.

Examples of waste include, but are not limited to the following:

  • A person making excessive office visits or accumulating more prescription medications than necessary for the treatment of specific conditions.
  • A provider ordering excessive laboratory tests such as a comprehensive metabolic panel, or group of blood tests, when only one test is needed.

Abuse

Abuse, is a behavior that, although normally not considered fraudulent, is inconsistent with accepted sound medical, business, or fiscal practices. The practices may, directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or which are medically unnecessary.

Examples of abuse include, but are not limited to the following:

  • Excessive charging for services or supplies;
  • Claims for services that don’t meet CMS medical necessity criteria
  • Breach of the Medicare/Medicaid participation or assignment agreements;
  • Improper billing or coding practices.

Summary

In lay terms, fraud, waste and abuse may also include:

  • Medical identity theft;
  • Billing for unnecessary services or items;
  • Billing for services or items not rendered;
  • Intentionally using codes for services to receive higher payments
  • Billing for non-covered services or items;
  • Giving Kickbacks;
  • Creating fictitious patients;
  • Creating fictitious providers;
  • Intentionally billing Medicaid for services that can be paid for by other means.
  • A provider ordering excessive laboratory tests such as a comprehensive metabolic panel, or group of blood tests, when only one test is needed.

Prevention and detection of fraud, waste, and abuse is not solely the government’s responsibility. TMBHO encourages all recipients and providers of services to become familiar with such definitions and to report suspicious activities as a way of making a valuable contribution in the fight against fraud and abuse.

TMBHO has a Compliance Officer (Kristy Lysell) to follow up on any reported incidents of Fraud, Waste or Abuse. The Compliance Officer reports up to the TMBHO Chief Executive Officer (and indirectly to the Governing Board) to ensure that such matters are fully investigated and taken seriously.

Reporting

To report suspected Fraud, Waste or Abuse please contact the TMBHO Compliance Officer in any of the following ways:

Kristy Lysell, Compliance Officer
TMBHO
612 Woodland Square Loop SE Suite 401
Lacey, WA 98503

You may also anonymously report suspected Medicaid fraud and abuse through the following contacts:

  • Health Care Authority (Apple Health eligibility fraud):
  • U.S. Department of Health and Human Services (HHS) OIG Hotline
    1-800-447-8477