Provider Rights in Suspected Fraud and Abuse Cases


If Fraud or Abuse of Benefits Is Suspected

If the Fraud and Abuse Department suspects potential fraud or abuse because of evidence such as reimbursement data, information from law enforcement or fraud organizations or complaints from members, providers, provider employees, vendors or 1199SEIU Benefit Funds’ staff, the 1199SEIU Benefit Funds will review the claim(s) in question and assign an investigator.

This investigation may include:

• Pre/post payment claims review;

• Medical record request and review;

• Data analysis;

• Verification of services (surveying patients, auditing charts);

• Onsite field audit request; and

• Provider monitoring.

Provider Notification

The Fraud and Abuse Department will notify providers of any investigations that may adversely affect payment.

Providers Have the Right to Challenge Fraud and Abuse Determinations

Providers have the right to challenge the 1199SEIU Benefit Funds’ initial fraud and abuse determinations. The provider may request a second review by the Fraud and Abuse Committee.

Decisions made in a court or by settlement may not be appealed to the 1199SEIU Benefit Funds.

If the appeal is unsuccessful, the 1199SEIU Benefit Funds will begin to recover lost monies by negotiating a settlement with the provider. If no settlement agreement can be reached, the 1199SEIU Benefit Funds will take whatever action is necessary to recover lost monies, such
as suspending future payments. Unsuccessful recovery efforts will ultimately result in removal from the 1199SEIU Benefit Funds’ network of participating providers; in some cases the 1199SEIU Benefit Funds may refer the provider to law enforcement and/or licensing boards.