Report Fraud, Waste and Abuse

Centene Corporation Bridgeway Health Solutions (Bridgeway) is dedicated to conducting business in an ethical and legal manner. As a key partner, it is critical that you understand that we are committed to preventing, detecting and responding to fraud, wrongdoing or any type of misconduct. If you ever have any concerns or are ever asked by anyone, including a Centene Bridgeway employee, to engage in any behavior that you believe is wrong, unethical or illegal, please immediately contact Bridgeway at the number below OR the AHCCCS Office of the Inspector General (OIG).

Our Pledge

Our Ethics and Compliance department will promptly review allegations of wrongful, illegal or unethical business practices by any Centene Bridgeway employee or any provider and when necessary report allegations of the Anti-Kickback Statute, Stark Law violations and the False Claims Act to government regulators.

Centene’s Ethics & Compliance Helpline
1-800-345-1642

Available 24 hours a day, seven days a week. Callers are not required to give their names and all calls will be investigated and remain confidential.

Local Contact Information
Cheyenne L. Ross, CCEP, CHC, CHPC, CPHQ
Vice President Compliance & Regulatory Affairs
1-480-567-9018
chross@centene.com

What Are Fraud, Waste and Abuse?

• Fraud refers to a false action that is used to gain something of value
• Waste is the misuse of services
• Abuse refers to overused or unneeded services

Fraud Statutes

The Anti-Kickback Statute is a criminal statute that prohibits anyone (not only physicians) from knowingly and willfully offering, paying, soliciting, or accepting anything of value to induce or reward patient referrals or generate Medicare or Medicaid business. When contracting with physicians for services the following factors are required:

• There is a legitimate need for those services
• The services are provided as described in the contract
• Compensation is consistent with terms of provider agreement or contract and conducted in an arm’s length transaction
• The arrangement is completely decoupled from the volume or value of Medicare or Medicaid business generated.
Violations of Anti-Kickback rules require proof of intent. Penalties can include fines, jail time, and exclusion from federal healthcare programs.

The Stark Law is a strict liability statute that does not require proof of intent-meaning even inadvertent infringements are illegal. Quite simply, it is illegal for physicians to refer patients for Medicare-insured “designated health services”—clinical lab services, home health services, physical therapy, etc.—to an entity in which they (or a comprehensive list of related family members) have a financial stake. Penalties for Stark violations can include fines, jail time and exclusion from federal health care programs.

The False Claims Act—prohibits the submission of “knowing” false claims to obtain federal funds. The United States may sue violators for treble damages (three times the government’s loss), plus $5,500 to $11,000 per false claim. The law is not limited to claims submitted with fraudulent intent. It also applies to “ostriches with their heads in the sand” who make false claims with “deliberate ignorance” or “reckless disregard” of truth or falsity, or “gross negligence.” Everyone involved in a scheme can be prosecuted-even “downstream” providers or subcontractors who receive federal funds through third parties, such as government contractors and HMO’s.

For fraud concerns pertaining to our Medicare Part D product, you may also report to the National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) at 1-877-7SafeRx or 1-877-772-3379.