As part of our efforts to improve the healthcare system, PA Health & Wellness has made a commitment to detecting, correcting, and preventing fraud, waste, and abuse. Success in this effort is essential to maintaining a healthcare system that is affordable for everyone.
Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program.
(18 U.S.C. § 1347) Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Unnecessary costs to the healthcare system, including the Medicare and Medicaid programs Improper payment for services Payment for services that fail to meet professionally recognized standards of care Services that are medically unnecessary
If you suspect fraud, waste, or abuse in the healthcare system, you must report it to PA Health & Wellness and we’ll investigate. Your actions may help to improve the healthcare system and reduce costs for our participants, customers, and business partners. To report suspected fraud, waste, or abuse, you can contact PA Health & Wellness in one of these ways:
PA Health & Wellness anonymous and confidential hotline at 1-866-685-8664 Pennsylvania Office of Inspector General at 1-855-FRAUD-PA (1-855-372-8372) Pennsylvania Bureau of Program Integrity at 1-866-379-8477 Pennsylvania Department of Human Services 1-844-DHS-TIPS (1-844-347-8477) Mail: Office of Inspector General, 555 Walnut Street, 7 th Floor, Harrisburg, PA 17101 Mail: Department of Human Services, Office of Administration, Bureau of Program Integrity, P.O. Box 2675, Harrisburg, PA 17105-2675 Make a Government Fraud Complaint Report Fraud and abuse
You may remain anonymous if you prefer. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, corporate law department, market medical directors or senior management).
Contact with relevant parties to gather information. This may include contacting participants to get a better understanding of the situation. For example, we may contact a participant to ask about a visit with his or her physician. We may ask the participant to describe the services provided, who provided the care, how long the member was at the office, etc. Requests for medical or dental records. We do this to validate that the records support the medical or dental services billed. It’s important that the health care provider submits complete records as requested. We rely on this information to make a fair and appropriate decision.
Notification of suspected fraud and abuse to law enforcement and CMS, if applicable, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare part C (medical) and part D (prescriptions) and any other applicable state and/or federal agencies. Some of the most common coding and billing issues are:
Billing for services not rendered Billing for services at a frequency that indicates the provider is an outlier as compared with their peers. Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered Billing for services that are actually performed by another provider Up-coding Modifier misuse, for example modifiers 25 and 59 Unbundling Billing for more units than rendered Lack of documentation in the records to support the services billed Services performed by an unlicensed provider but billed under a licensed providers name Alteration of records to get services covered
How to report an illegal activity in the healthcare setting in PA?
Take the Proper Steps Before Filing a Complaint > > > Take the Proper Steps Before Filing a Complaint If your health plan is a “managed care plan”, you may have certain rights under Act 68. Please Read Carefully Filing a complaint with the Attorney General may not preserve your appeal rights, pursuant to ACT 68 or Medicare. To preserve your rights, you must file a complaint or grievance appeal directly with your health plan or in conformance with the terms of your coverage. The Office of Attorney General does not give legal advice. If you have a problem with your insurance plan, you should “Take the Proper Steps”, as follows:
Call your plan’s member services department. Always call your plan’s member services department first. Give them a chance to solve the problem. Many problems are solved at this level in an informal manner. File a formal complaint or grievance with your plan. If your phone call to the plan does not solve your problem, call the plan again and tell them that you want to file either a formal complaint or a formal grievance. File a complaint with the Attorney General’s Health Care Section by: Calling – 1-877-888-4877, mailing in a or submitting an,
: Take the Proper Steps Before Filing a Complaint
What is unethical in nursing?
Avoiding Liability Bulletin – December 2013 As you know, state boards of nursing are empowered with the duty to administer and enforce the state nurse practice act and its rules. This duty is based on the board’s overall duty to protect the public from unsafe and/or incompetent practitioners.
- At first blush, you may think you know what a state board of nursing means by this phrase.
- Most of your guesses may be right.
- Examples include breaching nurse-patient confidentiality, theft of patient money, belongings or identity, and crossing nurse-patient professional boundaries.
- Some of these types of behaviors were discussed in an earlier bulletin that focused generally on what types of conduct a board of nursing could consider violations of the state act and/or rules.
The unethical, unprofessional or illegal conduct by a nurse licensee as basis for disciplining a nurse is expanding. No longer are the more “common” reasons you might think would violate this sanction are the only ones that are analyzed by a board when evaluating a nurse licensee’s conduct.
For example, one of the more recent examples that you should be aware of is when a nurse is convicted of driving under the influence (DUI). You might think this is a stretch, since a DUI has nothing whatsoever to do with your practice as a nurse or an APN. The DUI did not take place while the nurse was on duty.
However, in a recent California case (1), the California Board of Nursing and the California Appellate Court saw this conduct differently. In upholding a nurse’s discipline by the board of nursing for a conviction for “using alcohol in a dangerous way” and an “alcohol-related conviction”(language from the state nurse practice act and rules), the court held that there does not need to be a nexus between a licensee’s fitness to practice nursing and conduct for which the licensee was convicted.
The court continued that the duty of the board is to protect the public, and when a state legislature passes statutes and rules that indicate certain conduct is related to their professional qualifications, the board can take disciplinary action against the licensee. Although the California Nurse Practice Act and rules had listed specific language for conviction of crimes, for alcohol -related convictions, and for using alcohol in a dangerous way, this decision opens the door for acts and rules to be amended to include such specific language.
It also potentially allows other boards of nursing to bring disciplinary actions against nurses for “unprofessional conduct” that may not be specifically listed but result in a conviction of a DUI, shoplifting, driving on a suspended license, as examples, or other situations that raise a question as to the professionalism and ethics of the nurse licensee.
- Know your nurse practice act and rules and what both say about your conduct as a licensee and the obligations you must adhere to as a result of the license you possess;
- Pay attention to the specific language in both the act and rules that allows the board to take disciplinary action against you in a non- nursing practice issue;
- Remember to conduct yourself as a professional at all times, both while on duty and when not on duty;
- Carefully consider getting involved in any situation that may result in notoriety, an arrest, adverse publicity, or a conviction;
- Carefully consider what you post on any social media page or in an e-mail that might be considered “unprofessional” or “unethical”;
- Select your friends wisely and with care;
- Don’t drink and drive;
- Pay your state and federal income taxes and any student loans;
- Pay any child support for which you are responsible; and
- Monitor legislative changes to your state nurse practice act and/or rules.
FOOTNOTES
Sulla v. Board of Registered Nursing, 205 Cal. App.1195 (4 th District).
THIS BULLETIN IS FOR EDUCATIONAL PURPOSES ONLY AND IS NOT TO BE TAKEN AS SPECIFIC LEGAL OR OTHER ADVICE BY THE READER. IF LEGAL OR OTHER ADVICE IS NEEDED, THE READER IS ENCOURAGED TO SEEK ADVICE FROM A COMPETENT PROFESSIONAL.
What makes a nurse unprofessional?
According to the Medical Practice Act, unprofessional conduct includes “any departure from or failure to conform to the minimal standards of acceptable and prevailing medical practice and shall also include, but not be limited to the prescribing or use of drugs, treatment or diagnostic procedures which are detrimental to the patient as determined by the minimal standards of acceptable medical care.” In general, examples of unprofessional conduct include, but are not limited to, physical abuse of a patient, inadequate record keeping, not recognizing or acting upon common symptoms, prescribing drugs in excessive amounts or without legitimate reason, personal impairment (mental or physical) that hinders safely practicing within the scope of one’s license or certificate, performing duties beyond the scope of one’s license or certificate and dishonesty.
How do I report a health department anonymously in PA?
1-800-254-5164. Online form. Email a complaint.
What are two example of unethical practice?
Examples of Unethical Workplace Behavior – From a behavioral standpoint, a person can infer these trivial misdeeds resulted in adequate reinforcement to continue to act towards more extensive transgressions, eventually resulting in significant unethical behavior.
Misuse of Company Time
Misusing company time, whether for covering up for a person who arrived late at the workplace or modifying the attendance log, is usually the most significant unethical behavior example. It also comprises knowing a co-worker managing their business during work hours.
Abusive Behavior
Almost every modern workplace remains filled with managers who use their status and influence to mistreat others. Unfortunately, unless the circumstances involve gender, race, or ethnic origin, there is usually little to no legal defense against offensive behavior in the workplace, and abusive conduct is unethical.
Employee Theft
Whether it is to prevent tampering, not registering sales to skim, or exploiting expense reimbursements, employee theft is another example of unethical behavior.
Lying to Your Workforce
The quickest way to lose the confidence of your workforce is to lie to them. If you ask workers whether their supervisor or manager has lied to them within the earlier year, you may be surprised at the results.
Violating Company Cyber Policies
Cyber Slackers and cyberstalkers are the individuals who surf the internet when they should serve in the company. It is a significant, multi-billion-dollar issue for companies. So if you think checking your Instagram, Facebook, or Twitter account is no big deal, it is unquestionably an unethical issue.
Deliberate Dishonesty in the Workplace
Asking for recognition for someone else’s job, calling in sick to go to the hill station, sabotaging someone else’s work, and, in sales, falsifying the product or service to fulfill the target are all examples of unethical behavior in the workplace. Other instances of purposeful unethical behavior exist, but they present how destructive unethical behavior can be when used to undermine an individual’s rights and security.
What are unethical behaviors?
What is the difference between ethical and unethical behavior? – Unethical behavior can be defined as actions that are against social norms or acts that are considered unacceptable to the public. Ethical behavior is the complete opposite of unethical behavior.
Ethical behavior follows the majority of social norms and such actions are acceptable to the public. Examples of ethical and unethical behavior : Unethical : “A student used plagiarism on their final written assignment to get a higher grade” This is unethical because it goes against social norms and the majority of the people would find this act unacceptable.
Ethical : “A student worked hard on research for their final written assignment and used in text citations and references to earn a higher grade” This is ethical because it does not go against social norms and the majority of the people would find this act acceptable.
What is unprofessional Behaviour?
What is unprofessional behaviour? 1 Unprofessional behaviour includes repeated inappropriate behaviour, as well as one-off incidents that may be disruptive.2 The inappropriate behaviour or incident may apply to interactions with patients, other health care professionals and colleagues, or outside of work.
What is unprofessional misconduct?
Professional Misconduct in the Workplace There is a common sense approach to this. For example, if someone is frequently arriving twenty minutes late in the morning then this would be considered a minor issue that is likely to be resolved informally; however, if they deliberately stole an item from another member of staff then this would be classed as gross misconduct and may require formal,
Persistent latenessNot completing a piece of work on timeNot following a manager’s instructionDoing a piece of work incorrectlyNot managing your attendance correctlyNot following procedures properly
What are negative professional behaviors in nursing?
1. Introduction – Limited evidence exists examining the relationship of negative behaviors displayed among acute care hospital interprofessional team members, although several published studies have evaluated this phenomenon within single disciplines such as nurses or physicians,
Previous research among single disciplines supports that negative behaviors are associated with negative patient outcomes, decreased productivity, employee retention, satisfaction, engagement, and increased absenteeism, Professional and regulatory organizations such as the American Nurses Association, American College of Healthcare Executives, and the Joint Commission have responded to dangers of negative behaviors by developing position statements and implementing regulations to ensure hospitals have adequate prevention measures,
Negative behaviors encompass the continuum of less active, less intentional forms, such as incivility, to more active, more intentional forms, such as physical violence, Many terms exist within the literature to describe negative behaviors, including workplace bullying, violence, aggression, abuse, hostility, sabotage, and incivility.
- Primary characteristics defining the distinction between terms include frequency of behavior, and intentionality,
- Another defining characteristic includes whether the behavior is described directionally, such as between peers (lateral or horizontal) or between leader and follower (vertical), which describes incidents between leader and employee and may occur bi-directionally, most commonly from leader to employee but also possibly from employee to leader.
Antecedents to negative behavior within the workplace include leader characteristics, follower characteristics, interpersonal relationships, and contextual variables within the environment, Healthcare worker burden exists, evidenced by the psychological and emotional consequences of negative behaviors for the healthcare worker, including decreased self-esteem, decreased passion for the profession, depression, self-hatred, and feelings of powerlessness,
Additionally, negative behaviors in the healthcare work environment increase patient burden of care in the form of increased medication errors, delays in treatment, increased patient falls, and increased mortality, Despite extensive available literature related to patient safety, limited empirical data exist examining the relationship between negative behaviors and patient safety culture,
The objective of this study was to examine the presence of negative behaviors among interprofessional team members using the negative behaviors in healthcare survey (NBHC) within an acute care hospital system and evaluate how these negative behaviors impact patient safety culture, measured by the Hospital Survey on Patient Safety Culture (HSOPS).
How do I report a health code violation in PA?
To report a Public Health Emergency or AN IMMEDIATELY NOTIFIABLE CONDITION, please call 1-877-PA-HEALTH (1-877-724-3258) (available 24/7) – Want to submit feedback? Need to file a complaint? Visit the Customer Service page. View reportable conditions (requirements for healthcare facilities to report conditions are within this link.)
| Program Area | Phone Number |
|---|---|
| AIDS Factline | 1-800-662-6080 |
| Birth and Death Certificates | 844-228-3516 |
| Brain Injury Help Line | 1-866-412-4755 |
| Cancer | 1-800-4-CANCER |
| Healthy Baby Line | 1-800-986-BABY |
| Healthy Kids Line | 1-800-986-KIDS |
| Healthy Woman Line | 1-800-215-7494 |
| HMO Consumer Complaints | 1-888-466-2787 |
| Home Health Complaints | 1-800-254-5164 |
| Lead Information Line | 1-800-440-LEAD |
| Managed Care Consumer Inquires/Complaints | 1-888-466-2787 |
| Nurse Aide Registry | 1-800-852-0518 |
| Nursing Home Complaint Hotline | 1-800-254-5164 |
| Publication and Research Materials (PADOHPHIC) | 1-877-724-3258 |
| Special Kids Network | 1-800-986-4550 |
| Tobacco Quitline | 1-800-QUIT-NOW |
| V/TTY for Speech and /or Hearing Impaired Persons | 717-783-6514 |
| WIC Information | 1-800-WIC-WINS |
| | |
| EXECUTIVE OFFICE | PHONE NUMBER |
| Secretary of Health | 717-787-9857 |
| Office of Communications | 717-787-1783 |
| Office of Policy | 717-787-9857 |
| Office of Legislative Affairs | 717-783-3985 |
| Office of Legal Counsel | 717-783-2500 |
| Health Equity Office | 717-547-3315 |
| Office of Operational Excellence (OpEx) | 717-260-8928 |
| | |
table>
How do I report a personal care home in PA?
Are you concerned about quality of care in a Personal Care Home? – Where to Get Help: Talk directly to your Personal Care Home Administrator. They are responsible for the operation of the Personal Care Home (PCH). Each PCH is required to listen to your concerns and to have a system in place for addressing those concerns.
Y ou may file a complaint with the Bureau of Human Services Licensing through the BHSL online complaint form, by calling 1-877-401-8835 or by emailing [email protected], The Department takes all complaints seriously. If you request, the Department will return your calls during normal business hours Monday through Friday.
C omplaint investigations take many avenues, including collateral contacts, interviews, phone calls, record review and on-site inspections. Complaints are assessed for the level of health and safety risk to the residents. The time frames for complaint investigations are assessed based on a review of not only the complaint allegations, but also the licensing history of the facility, previous complaint allegations, and history of regulatory compliance.
Are you required to report suspected outbreaks of illnesses to your local health department?
Local Health Departments – Most states require that local health departments report outbreaks of suspected foodborne and waterborne illness to their state health department External,
How do I file a PA labor complaint?
Workers who believe that their rights have been violated in their workplace are encouraged to email the Fair Labor Section at [email protected] or file a complaint online.
Does PA have an ombudsman?
Mission Statement – “P ennsylvania Ombudsmen are federally mandated, legally-based and state certified via standardized training to actively advocate and give voice to older consumers of long-term care services, whether delivered in the community or a facility-based setting.
How do I report a hospital to the state of PA?
To report a Public Health Emergency or AN IMMEDIATELY NOTIFIABLE CONDITION, please call 1-877-PA-HEALTH (1-877-724-3258) (available 24/7) – Want to submit feedback? Need to file a complaint? Visit the Customer Service page. View reportable conditions (requirements for healthcare facilities to report conditions are within this link.)
| Program Area | Phone Number |
|---|---|
| AIDS Factline | 1-800-662-6080 |
| Birth and Death Certificates | 844-228-3516 |
| Brain Injury Help Line | 1-866-412-4755 |
| Cancer | 1-800-4-CANCER |
| Healthy Baby Line | 1-800-986-BABY |
| Healthy Kids Line | 1-800-986-KIDS |
| Healthy Woman Line | 1-800-215-7494 |
| HMO Consumer Complaints | 1-888-466-2787 |
| Home Health Complaints | 1-800-254-5164 |
| Lead Information Line | 1-800-440-LEAD |
| Managed Care Consumer Inquires/Complaints | 1-888-466-2787 |
| Nurse Aide Registry | 1-800-852-0518 |
| Nursing Home Complaint Hotline | 1-800-254-5164 |
| Publication and Research Materials (PADOHPHIC) | 1-877-724-3258 |
| Special Kids Network | 1-800-986-4550 |
| Tobacco Quitline | 1-800-QUIT-NOW |
| V/TTY for Speech and /or Hearing Impaired Persons | 717-783-6514 |
| WIC Information | 1-800-WIC-WINS |
| | |
| EXECUTIVE OFFICE | PHONE NUMBER |
| Secretary of Health | 717-787-9857 |
| Office of Communications | 717-787-1783 |
| Office of Policy | 717-787-9857 |
| Office of Legislative Affairs | 717-783-3985 |
| Office of Legal Counsel | 717-783-2500 |
| Health Equity Office | 717-547-3315 |
| Office of Operational Excellence (OpEx) | 717-260-8928 |
| | |
table>
What are PA mandated reporting laws?
Call ChildLine at 1-800-932-0313, –
Learn more about abuse and reporting at Keep Kids Safe.
Trained specialists are available 24/7 to receive referrals of suspected child abuse and general child well-being concerns. Mandated reporters are certain adults, who are legally required to report suspected child abuse if they have reasonable cause to suspect that a child is a victim of child abuse.
- The law requires that the mandated reporter identify themselves and where they can be reached.
- In addition to having documentation that the report was made, this information is also helpful so that if clarification on the situation or additional information is needed, the children and youth caseworker can contact the mandated reporter.
Mandated reporters can report by telephone or electronically through the Child Welfare Portal,
More information on mandated reporting,
In addition, permissive reporters are individuals who are encouraged to report suspected child abuse, although not required by law. Permissive reporters can make a report at any time they suspect a child is the victim of child abuse. Permissive reporters may report anonymously.
County children and youth agencies or the Office of Children, Youth and Families (OCYF) Regional Offices for investigation or assessmentLaw enforcement officials for investigationDepartment of Human Services program offices for review and possible licensing action
Other Languages To report suspicions of abuse and/or neglect of children in other languages, please call ChildLine at 1-800-932-0313 ( TDD: 1-866-872-1677). Caseworkers are available to offer assistance 24 hours a day, seven days a week.
What is the duty to report in PA Rules of Professional Conduct?
Rule 8.3 – Reporting Professional Misconduct (a) A lawyer who knows that another lawyer has committed a violation of the Rules of Professional Conduct that raises a substantial question as to that lawyer’s honesty, trustworthiness or fitness as a lawyer in other respects, shall inform the appropriate professional
How do I file a Hipaa complaint in Pennsylvania?
File a Security Rule Complaint – You may file a Security Rule complaint electronically via the OCR Complaint Portal, or using our Health Information Privacy Complaint Package, If you mail or fax the complaint, be sure to send it to the appropriate OCR regional office based on where the alleged violation took place.
OCR has ten regional offices, and each regional office covers specific states. Send your complaint to the attention of the OCR Regional Manager. You do not need to sign the complaint and consent forms when you submit them by e-mail because submission by e-mail represents your signature. Before You File a Complaint Don’t waste time filing a complaint we can’t investigate.
Review these questions before filing a health information privacy or security complaint with OCR : Are you filing a complaint against an entity that is required by law to comply with the Privacy and Security Rules? Not all entities are required to comply with the Privacy and Security Rules.
Doctors Clinics Hospitals Psychologists Chiropractors Nursing Homes Pharmacies Dentists Health Insurance Companies Company Health Plans Medicare, Medicaid, and other government programs that pay for health care
Does your complaint describe an activity that might violate the Privacy or Security Rule? If you are not sure, go ahead and file your complaint. But, OCR can only investigate complaints that allege an action or omission that fails to comply with the Privacy or Security Rules.
For example, a doctor can send your medical test results to another doctor without your permission if the doctor needs the information to treat you; this is not a violation of the Privacy Rule, so we would not investigate a complaint that described this situation. Did the activity occur after the Privacy and Security Rules took effect? OCR cannot investigate Privacy Rule complaints that occurred before April 14, 2003 because compliance with the Privacy Rule was not required until that date.
Similarly, OCR cannot investigate Security Rule complaints that occurred before April 20, 2005. Are you willing to give OCR your name and contact information? OCR does not investigate complaints filed without a name and contact information on the complaint.