Report Fraud, Waste and Abuse
Louisiana Healthcare Connections takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a waste, abuse and fraud (WAF) program that complies with Louisiana and federal laws. Louisiana Healthcare Connections, in conjunction with its management company, Centene, successfully operates a waste, abuse and fraud unit. Louisiana Healthcare Connections performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system; please review the Billing and Claims section of this handbook. Louisiana Healthcare Connections performs retrospective audits which, in some cases, may result in taking actions against those providers, individually or as a practice, commit waste, abuse, and/or fraud. These actions include but are not limited to:
- Remedial education and/or training to prevent the billing irregularity
- More stringent utilization review
- Recoupment of previously paid monies
- Termination of provider agreement or other contractual arrangement
- Civil and/or criminal prosecution
- Any other remedies available to rectify
Some of the most common WAF practices include:
- Unbundling of codes
- Up-coding services
- Add-on codes billed without primary CPT
- Diagnosis and/or procedure code not consistent with the member’s age/gender
- Use of exclusion codes
- Excessive use of units
- Misuse of Benefits
- Claims for services not rendered
If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential WAF hotline at 1-866-685-8664. Louisiana Healthcare Connections and Centene take all reports of potential waste, abuse or fraud very seriously and investigate all reported issues.
NOTE: Due to the evolving nature of wasteful, abusive and fraudulent billing, Louisiana Healthcare Connections and Centene may enhance the WAF program at any time. These enhancements may include but is not limited to creating, customizing or modifying claim edits, upgrading software, modifying forensic analysis techniques, or adding new subcontractors to help in the detection of adherent billing patterns.
Authority and Responsibility
The Louisiana Healthcare Connections Vice President of Compliance & Regulatory Affairs has overall responsibility and authority for carrying out the provisions of the compliance program. Louisiana Healthcare Connections is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse.
The Louisiana Healthcare Connections provider network will readily make medical records for review and submission in the event a provider is randomly selected for audit. Failure to comply with the submission of requested medical records can result in the recoupment of previously paid claims.
As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The MRR vendor will sign a HIPAA compliant Business Associate Agreement with Louisiana Healthcare Connections which allows them to collect PHI on our behalf.
The Louisiana Healthcare Connections provider network will cooperate fully in making personnel and/or subcontractor personnel available in person for interviews, consultation, grand jury proceedings, pre-trial conferences, hearings, trials and in any other process, including investigations.