Health Care Fraud, Waste and Abuse

Therapy Network of Puerto Rico (TNPR) wants to find and stop health care fraud and abuse. It is estimated that billions of dollars are lost annually due to health care fraud and abuse. TNPR takes its responsibility seriously to protect the integrity of the care its members receive, its Health Plans, and the Federal and State Programs it administers.

Fraud is defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit. Examples of healthcare fraud are:

  • Misrepresentation of the type or level of service provided;
  • Misrepresentation of the individual rendering service;
  • Billing for items and services that have not been rendered;
  • Billing for services that have not been properly documented;
  • Billing for items and services that are not medically necessary;
  • Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);
  • Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding).

Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

  • Misusing codes on a claim;
  • Charging excessively for services or supplies; and
  • Billing for services that were not medically necessary.

Both fraud and abuse can expose a provider or vendor to criminal and civil liability.

How Can I Help Prevent Fraud and Abuse?

  • Validate all member ID cards prior to rendering service;
  • Ensure accuracy when submitting bills or claims for services rendered;
  • Submit appropriate Referral and Treatment forms;
  • Avoid unnecessary drug prescription and/or medical treatment;
  • Report lost or stolen prescription pads and/or fraudulent prescriptions; and
  • Report all suspicions of fraud by contacting:
    • Call: 1 (800) 595-9631 or contact your TNPR Provider Relations representative who will forward your inquiry to the Compliance Department
    • Write: TNPR Compliance Department, 2001 South Andrews Avenue, Fort Lauderdale, FL 33316
    • Fax: 1.866.276.3667

What should you do if you suspect or have knowledge of fraud and abuse?

All TNPR providers are required to report concerns about actual, potential or perceived misconduct to the TNPR Corporate Compliance Department at the numbers/addresses noted above.

What happens to me if I report a concern?

TNPR takes its responsibility to protect your reporting of actual or suspected fraud and abuse seriously. No employee may threaten, coerce, harass, retaliate, or discriminate against any individual who reports a compliance concern. To support this effort, TNPR has enacted zero-tolerance policies and annually trains all personnel on their obligation to uphold the highest integrity when handling compliance related matters. Any individual who reports a compliance concern has the right to remain anonymous and TNPR commits to enforcing this right.

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