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About Us

Fraud, Waste and Abuse

Compliance Program

Standards of Conduct

We conduct business with the highest ethical standards, and our compliance program supports this. We've created the Medica Standards of Conduct to assist in understanding expectations for how we do business and to outline your responsibilities as a vendor that provides goods or services to Medica or our members. 

As a Minnesota Department of Human Services (DHS) and a Centers for Medicare and Medicaid Services (CMS) contracted organization, we apply these Standards of Conduct to our first tier and downstream entities.

View the Medica Standards of Conduct »



Reporting Policy

Under our Compliance Program, providers, vendors, contractors and Medica employees are required to promptly report any good faith belief of any suspected or known violation of the laws and regulations that govern our business, our Standards of Conduct, financial reporting and standards, or our Corporate Compliance Program and Medicare Compliance Program, including our Privacy or Security Programs.

View our Reporting Policy for Compliance, Fraud, Waste and Abuse, and Privacy »

Training for Providers

Compliance Program awareness training and Fraud, Waste and Abuse awareness training are required for employees, contractors and board members who provide health care services or administrative services for Medicare eligible individuals under the Medicare Advantage or Medicare Part D programs. Training is also required of downstream and related entities that provide health care services or administrative services for Medicare-eligible individuals. Training must occur within 90 days of a Medicare provider's initial contract (or at time of hire) and annually thereafter.

Effective January 1, 2016, all First Tier, Downstream and Related Entities (FDRs) should complete the two CMS web-based trainings. One is dedicated to understanding the elements of an effective compliance program, Medicare Parts C and D General Compliance Training (December 2015). The other focuses on detecting, correcting and preventing Fraud, Waste and Abuse (FWA), Combatting Medicare Parts C and D Fraud, Waste, and Abuse.  Follow these steps to access the trainings:

    1. Access the CMS Medicare Learning Network (MLN) Website: https://learner.mlnlms.com/Default.aspx# First time users must create an account. CMS offers help to complete this step; see the link on the MLN login page. Step 4 explains how to correctly populate the Select Organization screen. 
    2. In the MLN menu bar, select Training Catalog.
    3. Type the title of the first training in the search field, “Medicare Parts C and D General Compliance Training (December 2015). Select that training module.
    4. Select “Enroll.”
    5. Select Course Credit Options (Credit or no Credit) and Course Mode Options (Normal). Select Enroll in bottom right corner of screen.
    6. Select “Open Item” to start the training. There are three parts: introduction, compliance program training and post-assessment. You must complete all three before you can proceed.
    7. Complete the “Web-based Training Evaluation” found under the Transcript tab, on the left side of screen under Surveys.
    8. Print the certificate by selecting “View Certificate” on the Transcript tab. If “View Certificate” is not available, contact CMS’ help desk at CMS MLN, medlearn@cms.hhs.gov. You will not be able to view your Certificate until you complete the Training Evaluation.
    9. Complete steps 3-8 for the second training, “Combatting Medicare Parts C and D Fraud, Waste, and Abuse.

If you offer additional compliance training to your staff and downstream entities, you may not modify the CMS’ training content but you can add other topics specific to your organization’s annual training program.

In addition, you must review and agree to comply with our Standards of Conduct and Compliance Reporting Policy or comparable standards of conduct and policies of your own that meet the Centers for Medicare & Medicaid Services requirements.

Medicare Certified Providers

Providers that are Medicare Certified are exempt from taking the Fraud, Waste and Abuse awareness training. However, providers are still required to complete the Medicare Parts C and D General Compliance Training. 

Retention Policy for Training Documentation

Your organization should keep a copy of all documentation related to the Compliance Program training and Fraud, Waste and Abuse awareness training for the required record retention period of 10 years.  Medica will ask you for a copy of your training certificates annually. If you cannot provide us with the CMS certificates, you will need to complete our attestation confirming you have met the CMS training requirements.

Your record should include training dates, methods of training, training materials, and training logs identifying employees who received the training. Medica, CMS, or agents of CMS may request these records to verify that training occurred. 

If you cannot provide us with the CMS certificates, you will need to complete our attestation.

Questions

If you have any questions or concerns, you may call the Medica Provider Service Center at 800-458-5512.

Special Investigations Unit

Our Special Investigations Unit investigates allegations of fraud and abuse committed against Medica. The mission of the Special Investigations Unit is to prevent, identify, investigate, report and, when appropriate, recover money from health care fraud and abuse. These actions help ensure that member premium dollars are spent for legitimate health care purposes. 

The Special Investigations Unit is authorized to conduct post-payment reviews to ensure compliance with Medica requirements by monitoring the use of health services by members and the delivery of health services by Medica participating providers.

Examples of fraud include:

  • Billing for a medical service or equipment that was not provided.
  • Using another person's ID card to obtain medical services.

Learn more about our Fraud, Waste and Abuse Policies »

Report Fraud or Abuse

The Medica Reporting Policy applies to Medica providers, vendors and contractors, and Medica employees. There are several ways to report suspected fraud or abuse committed against Medica depending on the situation and how you are most comfortable reporting the issue.

General Reporting

You can report suspected fraud or abuse by filling out our Online Referral Form or calling either number below.

Complete our online Special Investigations Unit Referral Form »

Medica Special Investigations Unit

 Medica Fraud Hotline

952-992-8478 or 800-458-5512
Select option 1, option 8, ext. 2-8478

Available during business hours

866-821-1331

Available 24 hours a day, 7 days a week



Reporting Medicare Incidents

To report Medicare-related incidents:

 Medica Medicare Compliance

952-992-3400 or 888-906-0972



Anonymous Reporting

If you would prefer to remain anonymous when making a report:

 Medica Integrity Line
866-595-8495 


Reporting in Other Languages

If you would like to report in a language other than English:

Language  Phone Number
Spanish 952-992-2237 or 866-821-1331
 Russian  952-992-3893
 Somali 952-992-3214

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