HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. It is enforced by the Office for Civil Rights. HIPAA is comprised of two rules: the Privacy Rule and the Security Rule.
The Privacy Rule provides federal protections for individually identifiable health information held by covered entities and their business associates and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of health information needed for patient care and other important purposes.
What is Fraud, Waste and Abuse (FWA)?
Fraud: Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud and health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any money or property owned by, or under the custody or control of, any health care benefit program. Fraud occurs when an individual knows or should know that something is false and makes a knowing deception that could result in some unauthorized benefit to themselves or another person.
Abuse: Includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and or/intentionally misrepresented facts to obtain payment.
Acts of fraud can be committed by any person or entity, including insurance companies, beneficiaries, providers (physicians, labs, suppliers), pharmacies, or agents. Violations of the code of conduct, ethics, or any fraud, waste, or abuse must be reported. Everyone has the right and responsibility to report compliance issues and possible fraud, waste, or abuse. Not reporting fraud or suspected fraud can make you a party to a case by allowing the fraud to continue. You can report suspected FWA to the Health Solutions Compliance team directly or if you wish to report anonymously to the Corporate Compliance and Ethics Hotline at the number listed above.
You can also email the FWA department at MHHealthPlanFWA@memorialhermann.org.