Provider Manual

FRAUD AND ABUSE

The Department of Human Services (DHS) has mandated minimum requirements for Medical Assistance to ensure that VBH-PA and VBH-PA providers are preventing and detecting potential fraud, waste and abuse. Some common examples of fraud and abuse are:

  • Billing or charging Medical Assistance recipients for covered services
  • Billing more than once for the same service
  • Dispensing generic drugs and billing for brand name drugs
  • Incomplete or false records
  • Performing inappropriate or unnecessary services

In the Pennsylvania HealthChoices Behavioral Health Program Standards and Requirements, Appendix F obliges VBH-PA and VBH-PA providers to comply with Federal and State regulations and implement compliance programs and efforts that prevent and detect fraud, waste, and abuse. Subsequently, VBH-PA has implemented a compliance and program integrity plan with policies and procedures, trainings, and reporting responsibilities. The complete documentation for VBH-PA requirements are outlined on the VBH-PA Fraud and Abuse webpage available at the following address: http://www.vbh-pa.com/fraud-waste-and-abuse.

Policies and Procedures

VBH-PA has established policies and procedures to meet the DHS requirements specific to the prevention and detection of fraud, waste, and abuse (FWA). All VBH-PA providers are responsible to meet the requirements on the VBH-PA Fraud and Abuse webpage. VBH-PA will announce updates to or revisions to the VBH-PA Fraud and Abuse webpage in the Compliance Alert Section of ValueAdded, VBH-PA’s monthly provider newsletter.

Mandatory Trainings

All providers are required to have at least one representative attend the Annual Fraud and Abuse Training offered by VBH-PA. The provider or provider representative is responsible for reporting all information at the training to the provider and/or the entire staff of the provider agency. If a provider is unable to attend the Annual Fraud and Abuse Training, the provider is responsible to independently review the mandatory training and document when the training is completed within their records. However, VBH-PA recommends providers attend the training webinar since additional information will be available from the questions and answers portion of the training. Check the Provider Trainings webpage for Annual Fraud and Abuse Training dates.

All new providers are responsible to complete and review the documentation and previous trainings available on the VBH-PA Fraud and Abuse webpage. All new providers must attend one of the New Provider Fraud and Abuse Training Webinars offered each quarter. Check the Provider Trainings webpage for available dates.

Reporting

All providers are required to report suspect fraud and abuse. VBH-PA has established an Ethics Hotline (1-888-293-3027) to report suspected fraud and abuse that allows callers to remain anonymous. Additionally, there are several other methods to report fraud and abuse on the VBH-PA Fraud and Abuse webpage.

Additionally, DHS has established a hotline to report suspected fraud and abuse committed by any entity providing services to Medical Assistance recipients. The hotline number is 1-866-DPW-TIPS (1-866-379-8477) and operates between the hours of 8:30 AM and 3:30 PM, Monday through Friday. Voice mail is available at all other times. Callers may remain anonymous and may call after hours and leave a voice mail if they prefer.