Information for Contractors/Vendors Regarding
AlohaCare’s Fraud & Abuse and Gifts Policies
Revised January 2011
 
Fraud & Abuse
 
As a managed care organization contracted with government programs, AlohaCare is required by state and federal law to have a formal Fraud and Abuse Program. This program addresses the prevention, detection, and reporting of fraudulent and abusive situations. Such situations include, but are not limited to: the abuse, neglect, or exploitation of any individual receiving or providing services; and the loss, theft, misappropriation or overpayment of state and federal funds.
 
Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable federal or state law.
 
Abuse means practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicare or Medicaid (QUEST) program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicare or QUEST program.
 
Common Types of Fraud and Abuse: 
  •  Billing for services or items not provided
  •  Providing substandard or faulty services or items
  •  Providing and/or billing for unnecessary services or items
  •  Contract violations or making false statement to secure a contract
 
Under state law, penalties for false claim submission may include fines of $5000 but not more than $10,000. If the claim amount is $5000 or more, then an additional fine of three times the amount of damages. Under the Federal False Claims Act, penalties may range from $5,500 to $11,000 for each false claim, plus up to three times the amount of damages.  
 
AlohaCare takes many measures to detect false claim submissions and prevent incorrect payments. Under our QUEST contract with the State of Hawaii, AlohaCare is required to report all incidents of suspected fraud and abuse to the state Medicaid agency and the Medicaid Fraud Control Unit of the Attorney General’s Office within thirty (30) days of discovery. With our Medicare contract with the federal government, any violations made may be forwarded to Centers of Medicare and Medicaid Services or their designee, or the Office of Inspector General (OIG).
 
All contractors, vendors, or other types of business associates are required to participate in AlohaCare’s Fraud and Abuse Program and report instances of suspected fraud and abuse involving AlohaCare, an AlohaCare member, an AlohaCare provider, or AlohaCare supplier to the AlohaCare Corporate Compliance Officer. Anonymous submissions can be accepted. Ample detail must be provided to ensure that an appropriate and effective investigation can ensue. Reports of suspected fraud and abuse are confidential and should be sent to:

 AlohaCare
Attention: Corporate Compliance Officer
1357 Kapiolani Boulevard, Suite 1250
Honolulu, Hawaii 96814
 
Any person or entity with evidence of fraud may file a “qui tam” (whistleblower) lawsuit on behalf of the government. It is AlohaCare’s expectation that before this step is taken, the concern about fraud and abuse is reported to us and that we are given the opportunity to investigate and implement corrective actions.
 
Under the “qui tam” provisions, the person, or persons, making the report may be eligible to receive between 15 and 30 percent of Federal and State proceeds recovered. The federal and state law prohibits retaliation against anyone who in “good faith” reports and/or participates in an investigation of a false claim violation. Anyone who feels they have been unlawfully retaliated against should contact the state or federal government immediately.
 
Gifts
 
One of the principles of the AlohaCare Code of Conduct relates to Business Relationships. This principle states:
 
Business dealings with vendors, contractors and other third parties must be transacted free from offers or solicitation of gifts and favors or other improper inducements that would affect AlohaCare’s business in any way.
 
It is AlohaCare’s desire at all times to preserve and protect its reputation and to avoid the appearance of impropriety. This is particularly important to us, since all of our revenue is derived from the government. Consequently, no gifts of value can be accepted by any AlohaCare employee from anyone AlohaCare does business with (including at holiday time). Please keep this in mind as you do business with us, and avoid offering gifts and other items or services of value to AlohaCare employees. This includes gifts of food or meals.
 
For More Information
 
For more information regarding AlohaCare’s Fraud and Abuse Program or our Code of Conduct, or to request a copy of these documents, please contact AlohaCare’s Corporate Compliance Officer at (808) 973-1650 (Oahu) or 1-800-434-1002 (Neighbor Islands/Oahu toll free).