Healthcare Fraud, Waste and Abuse is estimated to add from 3 percent to 10 percent to all healthcare spending. Unchecked fraud and abuse in our system can cost taxpayers billions of dollars each year and divert critical healthcare dollars away from those who need the care. Protecting government dollars used for healthcare is an important part of all of our jobs.
- FRAUD is a false statement - made or submitted by an individual or entity - who knows that the statement is false, and knows that the false statement could result in some otherwise unauthorized benefit to the individual or entity. These false statements could be verbal or written.
- WASTE generally means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.
- ABUSE generally refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices; and that cause unnecessary costs to the healthcare system.
If you identify potential fraud, waste or abuse, please report it to us immediately so that we can investigate and respond appropriately.
You can send us an email, or call Provider Services at 702-242-7088, TTY 711 or the Compliance & Ethics HelpCenter at 1-800-455-4521. Please note: Health Plan of Nevada (“HPN”) and Sierra Health and Life Insurance Company (“SHL”) expressly prohibit retaliation against any person who makes a report in good faith.
The Centers for Medicare & Medicaid Services (“CMS”) modified certain rules and regulations of the Medicare Advantage and the Part D programs that state that a contractor’s compliance plan must include training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, directors, as well as first tier, downstream and related entities.
As a contracted provider for HPN, HPN Medicaid or SHL Medicare Advantage programs, you are considered a first tier or downstream entity and are subject to CMS’ rules. It is our responsibility to ensure that your organization is provided with appropriate training materials for your employees and applicable subcontractors. To facilitate that, we are providing your organization with training materials, which are made available on healthplanofnevada.com and sierrahealthandlife.com, under the Providers tab.
Annually, your organization must administer the training materials to your employees and applicable subcontractors. It is important that you maintain records of the training (i.e. sign in sheets, materials, and any other documentation utilized in the training). Documentation of the training may be requested by HPN or SHL, CMS, or an agent of CMS to verify that the required training has been completed annually.