Fraud, Waste & Abuse Prevention

At Universal Health Care Group (UHCG), we have a zero-tolerance policy on Fraud, Waste and Abuse (FWA), and everyone is responsible to make a difference. The FWA program is built around protecting our beneficiaries and we believe this 'member centric' vision is paramount to our overall mission of helping and protecting people. UHCG has designated primary responsibility for the FWA program to the Special Investigations Unit (SIU).

With national health care expenditures of $2.6 trillion and rising each year, comprising approximately 17.9% of our nation's Gross Domestic Product (GDP), it is imperative we curb the estimated 3% to 10% of FWA that plagues our health care system.The Medicare program, at a $525 billion spend in 2010, is unable to withstand the burden of unnecessary expenditure. UHCG is honored to serve our state and federal partners, and we understand how vital our role is in making an impact, and preserving the integrity of our health care system. The below chart shows the potential impact FWA has on our nation's health care system.

As part of the overall Compliance and FWA program, the SIU maintains written policies and procedures and adheres to the Corporate Code of Ethics which articulates the organization's commitment to comply with all applicable Federal and State standards, including measures to detect, correct, and prevent FWA. UHCG recognizes the importance of building the foundation of the Company FWA program around prevention versus post-payment recovery or a 'pay and chase' philosophy. UHCG places great emphasis on leveraging real time data, technology and staff intervention at an earlier stage in the entire health care cycle to reduce vulnerability, lack of transparency and impact to FWA. This serves as the cornerstone of our ability to protect our beneficiaries and the overall integrity of the health care system as a whole.

SIU Mission Statement

'The mission of Universal Health Care Group's (UHCG) Special Investigations Unit (SIU) is to protect the overall integrity of the healthcare system, as well as to protect UHCG members, providers, business partners and stake holders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential fraud, waste and abuse (FWA). The Company is committed to preventing and recovering dollars lost to FWA and partnering with state and federal law enforcement agencies to prosecute violators to the fullest extent of the law.'

Definitions and Examples

Fraud

Intentional misrepresentation to gain a benefit

Abuse

Any unsound business practice resulting in undue remuneration

Waste

Any unnecessary consumption of a healthcare resource

Services Not Rendered

Billing for goods and/or services that were never delivered or provided

Medical Necessity

Performing inappropriate or unnecessary medical procedures in order to increase payment

Unbundling

Using multiple billing codes instead of one billing code for a drug panel test in order to increase payment

Marketing Misrepresentation

Sales Agents falsifying marketing information to gain beneficiary enrollment

Falsification of Reports

Health Plans falsifying encounter data to increase profit

Up-coding

Billing for a higher level of service than was actually provided

Brand vs Generic

Billing for brand-named drugs when generic drugs are actually provided

Non-return of Overpayment

Being over-paid for service, but not reporting and/or returning that overpayment

Anti-Kickback

Winning or gaining a contract through kickbacks and/or bribes

Misrepresentation

Forging a physician's signatures to obtain pharmaceutical goods

Double Billing

Charging more than once for the same goods or services

Underutilization

Not providing adequate medical care to increase profits

Enrollment Fraud

Enrolling a beneficiary into a health plan without that person's knowledge

Theft of Services

Utilizing someone else's insurance card to receive services; either through stealing the card or having it provided by the true card holder

Reporting Health Care Fraud, Waste & Abuse

If you have a reason to believe Fraud, Waste or Abuse (FWA) may have been committed, please contact us immediately and together we can make a difference. Contact Options are listed below:

• Call the Confidential Universal SIU TIP line toll free at 1-877-386-6680
• You may E-mail the Universal SIU at FWA@univhc.com
• You may fill out the FWA reporting form on-line at www.univhc.com/about/fwa-form.php
• Mail your concern to the following address:
  Special Investigations Unit
  Universal Health Care
  100 Central Avenue, Suite 200
  St. Petersburg, FL 33701

You may also report to the following agencies:

• Florida Office of Financial Regulation, Division of Insurance Fraud: 1-800-378-0445
• Department of Health and Human services, OIG Medicare Fraud Hotline: 1-800-HHS-TIPS

Whistleblower Protection: The Civil False Claims Act also provides for protection for employees from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in terms and conditions of employment because of lawful acts conducted in furtherance of an action under the FCA may bring an action in federal district court seeking reinstatement, two times the amount of back pay plus interest, and other enumerated costs.

Helpful Fraud, Waste and Abuse Websites:

Office of Inspector General

Stop Medicare Fraud

Fraud and Consumer Protection

National Health Care Anti-Fraud Association (NHCAA)

Senior Medicare Patrol (SMP)

Additional FWA and Compliance Resources

Free Resources from CMS Outreach and Education MEDIC

Avoid Fraud, Waste & Abuse

First-Tier, Downstream and Related Entities (FDR) Compliance Library