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Fraud, Waste and Abuse

The tabs below outline our compliance program, our Special Investigations Unit and how to report a violation.

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

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.

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: 9/19/2018 8:32:36 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB02