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Recognizing and preventing fraud, waste, and abuse (FWA)
As a valued provider in the Magellan network, you play a critical role in maintaining the integrity of healthcare services. This includes complying with all federal, state, and Magellan requirements related to fraud, waste, abuse, and overpayments.
To support this effort, Magellan’s Special Investigations Unit may conduct desk or on-site audits as part of routine oversight or during an investigation. These reviews help ensure services are billed appropriately and member care is properly documented.
Some common examples of fraud, waste, and abuse include:
Billing issues
- Billing for services not rendered or performed
- Submitting false or misleading diagnosis, service, or care level information
- Charging multiple family members for the same therapy session
Documentation deficiencies
- Missing or delayed documentation to support billed services
- Medical records not completed/signed prior to claims submission
- Identical progress notes copied across visits
Improper billing practices
- Resubmitting denied claims with false information
- Failing to report and refund overpayments
- Billing for unnecessary or unbundled services
- Routinely waiving copays or deductibles
Billing code misuse
- Using in-person codes for services provided virtually, either by phone or video
- Using or excluding modifiers to bypass edits or increase payment
- Submitting incompatible or mutually exclusive codes on the same day
Compliance violations
- Exceeding regulatory limits, such as maximum group session sizes
- Providing services not medically necessary
- Billing for services performed by excluded or non-credentialed staff
- Billing under the name of a credentialed provider when services were delivered by unqualified personnel
What happens if FWA is identified?
If potential FWA or noncompliance is discovered, actions may include:
- Payment retractions for unsupported services. Any overpayments may be recovered via refund check or future claim offsets, in accordance with your contract and applicable regulations.
- Reporting to customers, oversight agencies and/or law enforcement as required.
- Pre-payment claim reviews, either for specific services or all claims.
- Termination of your provider agreement, in serious cases.
Additional resources
- For detailed policy information, refer to Section 4: Fraud, Waste, Abuse, and Overpayment in Magellan's National Provider Network Handbook (PDF), which includes:
- Expectations during audits and investigations
- Examples of fraud, waste, abuse, and overpayment
- Provider responsibilities
- If you have questions about your contract or documentation requirements, contact your network representative.
- For questions about audits or investigations, contact Magellan's Special Investigations Unit directly via email at (SIU@MagellanHealth.com) or via our hotline 1-800-755-0850 (you may remain anonymous).