Fraud, Waste and Abuse

MyTruAdvantage is dedicated to the detection, prevention, and correction of potential healthcare Fraud, Waste, and Abuse (“FWA”). Our FWA Program was developed in accordance with the following Federal and State statutes, regulations, and guidelines:

- Applicable State laws and contractual requirements
- Civil False Claims Act, 31 U.S.C. §§3729-3733
- Criminal False Claims Act, 18 U.S.C. §287
- Anti-Kickback Statute, 42 U.S.C. §1320a-7b
- 42 C.F.R. 422 and 423

- Regulatory guidance produced by the Centers for Medicare and Medicaid Services (CMS), including requirements in Chapter 9 of the Medicare Prescription Drug Benefit Manual and Chapter 21 of the Medicare Managed Care Manual.

The FWA Program has been developed to comply with all standards set forth by the regulations and laws of the United States Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS). The FWA Program and the FWA Program Description are reviewed periodically by MyTruAdvantage’s Compliance Committee with revisions made as needed.

Definitions
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.
Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically necessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other facts.

Examples of Fraud, Waste, and Abuse

Please report fraud, waste and abuse if you see it. There are many examples of fraud, waste and abuse. Some examples are below.

• A provider charges MyTruAdvantage for services it did not provide.
• A provider offers a MyTruAdvantage member money or kickbacks to use their services.
• A MyTruAdvantage member lends an ID card to someone else.
• A MyTruAdvantage member sells drugs they were prescribed or forges a prescription.
• A provider performs medically unnecessary services to receive payment from MyTruAdvantage.

FWA Hotline
MyTruAdvantage accommodates anonymous, confidential and private, good faith reporting of instances of suspected FWA. MyTruAdvantage maintains confidential reporting mechanisms that individuals can use to report suspected FWA. MyTruAdvantage’s FWA Hotline is available 24/7.
To report an issue by telephone, call toll-free at 844-255-7120;Please press #1 for MyTruAdvantage.
You can also email us at compliance@mytruadvantage.com