Fraud, Waste, and Abuse Prevention Program
While most people are honest, a small minority commit health care fraud and abuse. This costs health plans and government programs – and you – a lot of money every year. Incidents of fraud and abuse are low in Massachusetts when compared to other parts of the country. That doesn’t mean we can let out guard down, though. That’s why HNE has implemented a fraud, waste, and abuse prevention program.

Report Suspicious Activity
Please tell us if you see any suspicious activity. You can call our toll-free compliance hotline, email, or send us a letter via fax or mail.
•  Compliance Hotline: (800) 453-3959 (available 24/7; reports can be made anonymously)
•  Email: compliancedepartment@hne.com
  (please use secure messaging at https://hne-mail.com)
•  Fax: (413) 233-2806
• HNE mailing address:
  Health New England, Inc.
  Attn: Compliance Officer
  One Monarch Place
  Springfield, MA 01144-1500

HNE cannot retaliate if you report suspicious activity. When making a report, please provide as much detail as possible. Names, dates, and a description of the issues in question are helpful. For example, you may wish to describe why you think an activity is a cause for concern. If possible, please include your name and telephone number. That way, we can contact you if we have any questions during our investigation. If you wish to use email to report a concern, please use secure messaging to protect your confidentiality. For example, you may send and receive secure messages by logging in to the HNE Secure Mail Message Center. Go to https://hne-mail.com, create a login, and compose a message. You will be able to log in later to receive our response.

What are Fraud, Waste, and Abuse?

Fraud is the intentional use of false statements to cheat another person or company out of something of value. It includes any act that constitutes fraud under state and federal law.

Waste is any unnecessary cost that results from poor or inefficient practices.

Abuse is an activity that goes against sound business, monetary or medical practices. Abuse may include practices by providers, members, or customers that result in unnecessary costs to the health plan.
Suspicious Activity is any activity that you think is fraudulent, wasteful, or abusive. Here are some examples:

Examples of Suspicious Activity by Providers
•   Altering medical records
•   Billing for non-covered services as if covered
•   Billing for services that weren’t provided
•   Falsely certifying that services were medically necessary
•   Kickbacks and bribery
  •  Use of unlicensed staff
    • •   Certain billing activity, like “unbundling" or “upcoding”
        • Unbundling is billing for each piece of a service, instead of for the service as a whole
        • Upcoding is billing for a cosstlier service than one provided

    Examples of Suspicious Activity by Members
    •   Adding someone to your plan who is not your dependent
    •   Not taking a dependent off a policy when they are no longer eligible
    •   Forging or altering bills or receipts to get payment from the health plan
    •   Forging or altering a prescription
    •   Selling your prescription drugs to someone else
    •   Getting medical care and benefits with someone else’s insurance card
    •   Letting someone use your insurance card to get medical care and benefits

    Examples of Suspicious Activity by Brokers or Agents
    •   Altering documents
    •   Accepting or offering kickbacks or bribery
    •   Falsifying or misrepresenting information to get better rates. This is called “clean sheeting"
    •   Failure to disclose information that may affect conditions of coverage
    •  Sale of non-existent policies

    Examples of Suspicious Activity by Employer Groups
    •   Providing false group information to get coverage
    •   Misrepresenting eligibility for coverage
    •   Falsifying an employee hire date to modify the date of health care coverage
    •   Falsifying an employee termination date to eliminate premium payments

    Overview of Fraud and Abuse Laws

    Federal False Claims Act
    This law makes it illegal to “knowingly” submit false or fraudulent claims for payment or approval to the federal government. Penalties for violations include penalties of $5,500 to $11,000 plus three times the damages for each false claim. Violations could result in criminal prosecution and conviction as well as exclusion from the federal government program or contract.

    Massachusetts False Claims Act
    Modeled after the federal False Claims Act, this law makes it illegal to make false claims against the commonwealth or a political subdivision of Massachusetts.

    Massachusetts False Health Care Claims Act (also known as the Massachusetts Insurance Fraud law)
    This law makes it illegal to submit fraudulent bills to private health insurers and other health care payers. Violators are subject to criminal prosecution. The health insurer or payer is entitled to bring a civil action to recover the amount paid, along with attorneys’ fees and the costs of investigation.

    Whistleblower and Whistleblower Protections
    Both the federal False Claims Act and the Massachusetts False Claims Act include provisions to encourage private citizens who know about fraud to file suit against those that committed the fraud. The government decides whether or not to join in the suit. If a suit is successful, the “whistleblowers” are awarded a percentage of the amount recovered. These laws also include important protections for whistleblowers. The laws make it illegal to retaliate against those participating in a whistleblower action. If an employer retaliates in any way against an employee, the employee may bring an action against the employer. Settlement may include reinstatement, two times the amount of back pay plus interest, attorney’s fees, and damages.
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