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MARKETPLACE FRAUD How the Assistance Network can Prevent, Detect, and Report suspected fraud.

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Presentation on theme: "MARKETPLACE FRAUD How the Assistance Network can Prevent, Detect, and Report suspected fraud."— Presentation transcript:

1 MARKETPLACE FRAUD How the Assistance Network can Prevent, Detect, and Report suspected fraud

2 2 Overview This training will help you Define Fraud Understand who is involved in fighting fraud Understand how to prevent fraud in the Marketplace Recognize potentially fraudulent situations Learn how to report potential fraud

3 3 What is Fraud? Fraud is defined by Federal law (42 CFR 455.2) as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.” Waste is defined as the thoughtless or careless expenditure, consumption, mismanagement, use, or squandering of public resources Abuse is defined as the intentional destruction, diversion, manipulation, misapplication, or misuse of public resources

4 4 Who is Involved in Fighting Fraud? Colorado Division of Insurance o DORA's Division of Insurance regulates the insurance industry and assists consumers and other stakeholders with insurance issues. Colorado Attorney General Department of Law The Consumer Protection Section protects Colorado consumers and businesses against fraud Local Law Enforcement o Local Law Enforcement agencies take reports of identity theft and fraud The Federal Trade Commission o The FTC works to prevent fraudulent, deceptive and unfair business practices Health and Human Services Office of Inspector General o The OIG is dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs. Connect for Health Colorado o C4HCO oversees and monitors the activities of employees, contractors, and grantees to prevent fraud YOU! o Assistance Network staff help protect customers and the government by protecting customer information, detecting potential fraud, and reporting it!

5 5 Preventing Fraud in the Marketplace To prevent fraud in the Marketplace, encourage customers to: Protect their Social Security Numbers Shred documents containing healthcare information or other personal information Not to give information over the telephone unless the person requesting has proven they have the information (like and insurance carrier or the Marketplace) Review information from health plans to make sure only services, equipment, and prescriptions used by the household members are listed Not to give information out to anyone who calls or comes to their home uninvited Not to respond to requests for person information End and report suspicious calls and visits

6 6 Customer Protection in the Works Connect for Health Colorado Certified Logo o Tell customers to look for the Connect for Health Colorado logo on websites and materials Tell customers expect assisters to ask for authorization This helps keep track of who has assisted This helps ensure that assisters are Certified by the marketplace or a Designated Organization Connect for Health Colorado issued photo badges

7 7 Examples of Fraud Involving Customers Someone has used another person’s information to get health insurance through the Marketplace An agent/broker or Health Coverage Guide has used false information to mislead a customer into enrolling in a health insurance plan Someone has made an unsolicited request for a customer’s personal information in order to enroll them in health insurance through the Marketplace Someone has requested or taken money from a customer to enroll them in health insurance through the Marketplace A customer knowingly and purposely falsifies information on a Marketplace application to qualify for coverage Someone encourages a customer to purposely falsify information on a Marketplace application for coverage

8 8 Best Practices to Prevent Grant Fraud Use program goals and scope of work when developing work plans o Report concerns with performance or measurements early o Work with Connect for Health Colorado to revise when necessary Use grant documents as guidance for spending o Use internal controls to monitor spending o Make sure staff time and payroll reports are accurate for grant project o Keep itemized receipts and invoices o Use internal policies when appropriate Monitor for Conflicts of Interest o Observe interactions between staff, partners, vendors, and customers o Consider Conflict of Interest provisions in grant details when partnering o Report potential conflicts of interest o Employ mitigation plan if potential conflicts are discovered

9 9 Examples of Grant Agreement Fraud A Health Coverage Guide or Assistance Site solicits gifts for assisting customers A Health Coverage Guide misuses time, equipment, or funds from the grant project An Assistance Site bills more than one grant for the same work An Assistance Site receives funding for staff work that was not done An Assistance Site alters receipts to receive funding An Assistance Site misrepresents the project status to continue receiving funding

10 10 Reporting Fraud If you or your customer thinks fraud may have occurred, report it! AgencyContact InformationDescription Division of Insurance(303) To report agent/broker or health claims fraud Attorney General To report fraudulent phone calls and scams Local Law EnforcementCheck locallyTo report identity theft, fraud, and scams The Federal Trade Commission To report identity theft HHS Office of Inspector General To report Marketplace enrollment with stolen information Connect for Health Colorado To report a complaint about an Assistance Site or Marketplace activitiy

11 11 Connect for Health Colorado Web Form Under the Connect heading, follow the Resources for Customers link; Click on ‘submit a report’ o fraud/ fraud/


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