BenefitMall Anti-Fraud Plan

BenefitMall (Mather & Strohl) Anti-Fraud Plan

BenefitMall is committed to helping fight against health care fraud and abuse. We offer a variety of education and training material on fraud and abuse.

Listed below are just some of the steps BenefitMall has taken to combat health care fraud and abuse:

  • Company-wide anti-fraud training curriculum
    • Graded health care fraud and abuse quiz
  • Continuous education of our brokers, groups, employees, subcontractors, vendors on health care fraud and abuse (posted on our intranet-site):
    • Health care laws and regulation
    • Links to additional resources provided by Health and Human Services Centers for Medicare & Medicaid Services
  • Job aids and supplemental training guide on fraud and abuse
  • Annual review and assessment conducted to ensure awareness of fraud, waste, and abuse

Fraud and abuse cost taxpayers billions of dollars and put beneficiaries’ health and welfare at risk. It is estimated that 60 billion dollars are lost annually due to health care fraud and abuse. All BenefitMall’s employees, subcontractors, and vendors are required to report any suspicious fraud and abuse activity to our compliance team.

What is Health Care Fraud and Abuse?

According to the department of Health and Human Services Centers for Medicare & Medicaid services, fraud is defined as making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. Fraud includes the obtaining of something of value through misrepresentation or concealment of material facts. Fraud schemes range from solo to broad-based operations by an institution or group.

Anyone can commit health care fraud. Fraud is defined as intentionally executing, or attempting to execute, a plan to obtain money or value from Medicare using deception. Examples of health care fraud include but are not limited to the following:

  • Internal Theft.
  • Falsifying eligibility.
  • Misappropriation of premiums.
  • Misrepresentation of data collected through the application submission and underwriting process.
  • Misrepresentation of level of services provided.
  • Knowingly submitting false claims, or making misrepresentations of fact, to obtain a federal Health Care payment for which no entitlement would otherwise exist.
  • Falsifying claims or medical records to receive a higher payment amount.
  • Adding someone to a plan that they do not qualify for.
  • Billing for items and/or services not medically necessary.
  • Misrepresenting dates, frequency, duration, or description of services rendered.

Abuse is defined as actions or practices that directly or indirectly result in unnecessary cost to the Medicare Program, and that do not provide patients with medically necessary services or meet professionally recognized standards of care. Examples of health care abuse include, but are not limited to the following:

  • Failure to maintain adequate health care or financial records.
  • Waiving deductibles or claims.
  • Improper billing practices. Billing for unnecessary medical services.
  • Misusing codes on a claim, such as upcoding or unbundling codes. Upcoding is when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement. It could also include enrolling someone in the wrong plan by mistake.
  • Refusing access to health care and medical records.

The difference between fraud and abuse depends on the specific facts, circumstances, intent, and knowledge. Both are considered non-compliance. Fraud and abuse can also expose our employees and our health care vendors or providers to criminal and/or civil liability.

How to prevent fraud and abuse?

Having awareness of health care fraud and abuse

  • Understanding and awareness of health care state and federal laws and regulations
  • Verifying and validating that groups, brokers, members are who they say they are
  • Ensuring complete accuracy of health care and medical records
  • Report all suspicion of fraud and abuse to BenefitMall’s Compliance team

How to report fraud and abuse?

To aid in the investigation of any allegation of fraud and abuse, BenefitMall must have the following information:

  • Name of the person who committed the fraud and/or abuse
  • Date and time the fraud and/or abuse occurred
  • Location where the fraud and/or abuse occurred
  • Description in detail of the fraud and/or abuse

Note: It is important to provide BenefitMall with your name, phone number, and address in the event we may have additional questions regarding your allegation. At BenefitMall, reports are treated confidentially and may be made anonymously.

You may file your request by one of the following resources listed below:

  1. Send an e-mail:
  2. Mail your information to our corporate address listed below:
    BenefitMall Compliance Department, 12404 Park Central Drive, Suite 400S, Dallas, TX 75251
  3. Contact our BenefitMall Ethics Hotline at: 855-819-1247

At BenefitMall, we take responsibility to protect your reporting of suspected fraud and abuse seriously. No one may threaten, retaliate, harass, or discriminate against any individual who reports a compliance concern.

Additional Resources

CMS Training Courses:

Medicare Fraud, Waste, & Abuse, Training Presentation:

Training Modules include:

  • Introduction
  • Medicare Fraud & Abuse
  • Medicare Fraud & Abuse: Laws and Penalties
  • Physician Relationship with Payers, Other Providers, and Vendors
  • Medicare Anti-Fraud and Abuse Partnerships and Agencies
  • Report Suspected Medicare Fraud & Abuse
  • Assessment