Skip to Main Content
Administrative Resources

Medica Administrative Manual Home > Fraud and Abuse

Compliance and Fraud, Waste and Abuse

Training for Providers

Providers that are contracted with Medica are required to complete general Compliance and Fraud, Waste and Abuse (FWA) awareness training. Training is required for employees, contractors and board members who provide health care services or administrative services for Medicare eligible individuals under the Medicare Advantage or Medica 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.

All First Tier, Downstream and Related Entities (FDRs) have the option to offer their own compliance training. CMS also has available two CMS web-based trainings:

  • Medicare Parts C and D General Compliance Training
  • Combating 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. 

General Compliance Training: Medica communicates the CMS General Compliance training to their FDRs within 90 days of the time of contract and annually thereafter. Additionally, Medica provides and communicates the Standards of Conduct and Reporting Policy, or you can choose to use your own entity’s documentation.

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 Compliance and Fraud, Waste, and Abuse 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. 

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. 

On an annual basis Medica mails each contracted provider a letter requesting training and attestation forms be submitted to Medica to attest training was completed.

Questions

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

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.

Medica Standards of Conduct – Business Partners (PDF)



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.

Compliance Reporting and Investigation Policy and Procedure (PDF)

Special Investigations Unit

Medica's Special Investigations Unit investigates allegations of fraud and abuse on behalf of Medica and its clients. 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 investigations to ensure compliance with Medica requirements by monitoring the use of health services by members and the delivery of health services by 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.

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 online to our Special Investigations Unit or by calling either number below.

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

Date: 3/29/2020 7:27:00 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01