CurrentMVP Health CarePolicy N/A

Fraud, Waste and Abuse Compliance Policy

Governs MVP Health Care's procedures to detect, prevent, investigate, and report fraud, waste, and abuse in Government Programs (Medicare Advantage/Part D, Medicaid, Child Health Plus) and describes applicable federal and New York state laws; affects MVP employees, providers, contractors, subcontractors, and members.

Policy Summary

PayerMVP Health Care

PolicyFraud, Waste and Abuse Compliance Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReport potential fraud and abuse to the SIU via the 24-hour toll-free hotline or to the Ethics & Integrity Hotline.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24/7SIU hotline availability

1-877-835-5687SIU hotline

1-888-357-2687Ethics Hotline

$11k–$23kFalse Claims Act penalties

$6k–$12kNY per-claim penalties

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

EthicsPointOnline reporting portal

Fraud, Waste and Abuse: Coverage Criteria and Legal Overview

Fraud, Waste and Abuse Coverage Criteria and Legal Summary

Procedures and legal consequences summarized for fraud, waste, and abuse:

Maintain a Corporate Compliance Program and Special Investigations Unit (SIU) to detect, prevent, investigate, and recover losses from fraudulent and abusive actions.

Provide and maintain a 24-hour SIU toll-free hotline (1-877-835-5687) and an Ethics & Integrity Hotline (1-888-357-2687) for reporting potential fraud and compliance concerns.

Report and return overpayments within 60 days of discovery as required by PPACA Section 6402; failure to return known overpayments may result in civil monetary penalties up to $50,000 or treble damages.

Legal remedies (examples)

False Claims Act liability: civil money penalties and treble damages; qui tam actions permitted with whistleblower protections.
Program Fraud Civil Remedies Act (PFCRA): administrative penalties (e.g., $5,000 per wrongfully filed claim plus assessment of twice the amount paid).
Civil Monetary Penalties Law (CMPL): authorizes CMPs up to $50,000 per violation and assessments up to three times the amount claimed or remuneration involved.

Do not offer or accept remuneration in exchange for referrals in violation of the Anti-Kickback Statute; violations may lead to criminal penalties, civil monetary penalties, and exclusion from government programs.

Comply with Stark Laws (physician self-referral prohibitions) to avoid prohibited referrals where a financial relationship exists for Medicare/Medicaid payable services.

Recognize federal criminal health care fraud statutes (e.g., 18 U.S.C. § 1347) that prohibit schemes to defraud health care benefit programs and carry fines and/or imprisonment.

Under Medicaid regulations (18 NYCRR Part 521), false claims and false claim statements are unacceptable practices subject to sanctions such as censure, repayment, and exclusion from Medicaid participation.

Prohibited conduct and remedies

Conduct and penalties that may lead to criminal or civil liability under New York law include:

Prohibited conduct

Insurance fraud: filing a health insurance claim known to be false (New York Penal Law Article 176). Penalties vary by amount and repeat offenses (may be misdemeanor or felony).
Health care fraud: knowingly filing with intent to defraud a claim for payment that contains false information or omissions (New York Penal Law Article 177). Penalties vary by amount and may include fines, imprisonment, and treble damages for overstated amounts.
Tampering with public records and offering a false instrument for filing (New York Penal Law §§ 175.xx): knowingly altering, concealing, or presenting false records to a public office, which may result in criminal charges.
Criminal impersonation: assuming another's identity with intent to defraud, deceive, or injure (New York Penal Law Article 190).

Civil and administrative remedies

Legal Statutes and Coding References

Legal statutes referenced (no billing/CPT/HCPCS codes provided)mixed

31 U.S.C. §§ 3729-3733	False Claims Act (federal) - imposes liability for knowingly filing false claims, using false records, conspiring to defraud, or avoiding obligations to pay government.
42 U.S.C. § 1320a-7a	Civil Monetary Penalties Law (CMPL) - authorizes civil monetary penalties for health care fraud, including penalties up to $50,000 per violation and assessments.
New York State Finance Law, §§ 187-194	New York State False Claims Act - modeled after federal FCA; provides liability for knowingly presenting false claims to the state or Medicaid managed care plans with civil penalties of $6,000 to $12,000 per claim and treble damages; allows qui tam actions and whistleblower protections.

Reporting and SIU Investigation / Provider Reporting Responsibilities

Prior Authorization

Report potential fraud to SIU via 24‑hour hotline

Report potential fraud and abuse to MVP’s Special Investigations Unit (SIU) using the SIU toll‑free 24‑hour hotline (1‑877‑835‑5687) or to the Ethics & Integrity Hotline (1‑888‑357‑2687); the SIU acts on internal and external referrals and uses claim data extracts to identify suspicious activity.

Use SIU hotline 1‑877‑835‑5687 for direct reporting of potential fraud and abuse.
Use Ethics & Integrity Hotline 1‑888‑357‑2687 (anonymous reporting available) for compliance concerns.
SIU investigates referrals from internal and external sources and analyzes claim data extracts to detect suspicious activity.

Note

Employees should report suspected fraud via Ethics & Integrity Hotline or online

Employees are encouraged to report suspected fraudulent activity via the Ethics & Integrity Hotline (1‑888‑357‑2687) or online at www.EthicsPoint.com; calls are received by EthicsPoint/NavexGlobal and may be made anonymously.

Key Definitions and Offenses

inv-06: 'Knowingly' — meaning and implications

DefinitionHaving actual knowledge that the information on the claim is false; acting in deliberate ignorance of whether the claim is true or false; or acting in reckless disregard of whether the claim is true or false.

Legal consequence (FCA)Persons liable under the False Claims Act may face civil money penalties between $11,463 and $22,927 per claim and treble damages.

Qui tam implicationIndividuals with knowledge may file suit on behalf of the government and may be entitled to a share of recovered amounts.

inv-07: 'Government Programs' — scope and role

DefinitionMedicare Advantage and Part D, Medicaid, and Child Health Plus (collectively 'Government Programs').

MVP status

Policy Summary

PayerMVP Health Care

PolicyFraud, Waste and Abuse Compliance Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReport potential fraud and abuse to the SIU via the 24-hour toll-free hotline or to the Ethics & Integrity Hotline.

SourceLink

On This Page

State civil damages: under New York law, violators who obtain false payments may be ordered to pay three times the amount overstated (treble damages).
Department of Health sanctions: in addition to repayment, the Department may impose additional per-item or per-service penalties and may exclude providers from Medicaid participation.

Ethics & Integrity hotline: 1‑888‑357‑2687 (anonymous reporting available).

Online reporting portal: www.EthicsPoint.com.

Calls are received and managed by EthicsPoint/NavexGlobal, an independent vendor.

MVP participates as a Government Programs contractor and is subject to specific federal and state regulatory requirements.

Policy contextPolicy provided to comply with Section 6032 of the Deficit Reduction Act of 2005 and to describe procedures for preventing and detecting fraud, waste and abuse in Government Programs.

inv-08: Tampering with Public Records — definition and elements

DefinitionKnowingly removing, mutilating, destroying, concealing, making a false entry in, or falsely altering any record or written instrument filed with or constituting a record of a public office when lacking authority.

Statutory referenceNew York Penal Law §§ 175.20–175.25.

Element: mens reaRequires that the actor act 'knowingly' in performing the tampering conduct.

inv-09: Offering a False Instrument for Filing — definition and elements

DefinitionKnowingly presenting or offering a written instrument that contains false information to a public office with the knowledge or belief that it will be filed, registered, recorded, or become part of public records.

Statutory referenceNew York Penal Law §§ 175.30–175.35.

Key elementThe actor must know the instrument contains false information and intend that it be filed or become part of official records.

inv-10: Insurance Fraud — filing false health insurance claims

DefinitionFiling a health insurance claim knowing that it is false.

SeverityMay be charged as a Class A misdemeanor or as a Class B, C, D, or E felony depending on the amount involved; repeat offenses can be a Class D felony.

ContextDefined under New York Penal Law Article 176 and applies to false health insurance claims submitted to payers or programs.

inv-11: Health Care Fraud — definition and penalties overview

DefinitionKnowingly filing, with intent to defraud, a claim for payment that intentionally contains false information or omissions.

PenaltiesMay be a Class A misdemeanor or a Class B, C, D or E felony depending on the amount; New York law permits damages of three times the overstated amount and additional per-item or service penalties by the Department of Health.

ApplicationCovers claims submitted to government health programs and can trigger both criminal and civil remedies under state law.

inv-12: Criminal Impersonation — definition and consequences

DefinitionAssuming another person's identity with the intent to defraud, deceive, or injure another.

ClassificationMay be charged as a misdemeanor or a felony depending on circumstances and harm caused.

RelevanceApplies where false identity is used to obtain payments or benefits from health care programs or to conceal fraudulent activity.

inv-13: Whistleblower Protections — qui tam relator / protections

DefinitionQui tam relator / whistleblower: an individual who brings an action under the False Claims Act on behalf of the government.

ProtectionsFederal law prohibits employer retaliation against employees who file FCA suits; New York law prohibits employer retaliation for disclosures of practices that violate law and threaten public health or constitute health care fraud.

Reporting resourcesEmployees are encouraged to report potential fraud anonymously via the Ethics & Integrity hotline (1-888-357-2687) or online at www.EthicsPoint.com; FCA relators may be entitled to a share of recoveries.

inv-14: False Claims Laws — role and mechanisms

PurposeCreate mechanisms for preventing, detecting, investigating, and punishing fraud, waste, and abuse in federal and state health care programs.

Enforcement toolsInclude civil money penalties, treble damages, administrative remedies, and qui tam actions under the False Claims Act.

Program complianceSupport MVP's Corporate Compliance Program and SIU investigative authority to identify and recover improper payments and refer matters for civil or criminal action.