Program Integrity

Fraud:  Intentional Deceit

• Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist;

• Knowingly soliciting, paying, and/or accepting remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs; or

• Making prohibited referrals for certain designated health services

Waste:  Inefficient Practices

• Waste, according to Centers for Medicare and Medicaid Services (CMS), is the result of honest mistakes and human errors.

• Waste implies no malicious intent. But, as the term suggests, spending is inefficient and costly.

Abuse:  Bending the Rules

• Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicaid Program.

• Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and priced fairly.

Eastpointe recommends that the Provider network conduct voluntary Provider Self-Audits and challenge audits in accordance with North Carolina General Statue 108c-5. Voluntary Self-Audits are to help identify instances where services reimbursed by Eastpointe are not in compliance with contract requirements, state and federal policy.

Eastpointe would like to hear from you regarding any Program Integrity Referrals that you may have.

If you have questions, or need assistance, please contact Eastpointe Program Integrity at pi@eastpointe.net