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SELECTHEALTH FRAUD AND ABUSE PROGRAM

 

The SelectHealth Special Investigations Unit (SIU) has the primary responsibility of investigating fraud and abuse for SelectHealth. The SIU works very closely with the State of Utah Insurance Fraud Division in sharing issues of concern, referring insurance fraud and abuse cases for investigation, and in complying with the State of Utah mandatory reporting requirements for fraud. The SIU also works with the State of Utah Department of Professional Licensing (DOPL) in reviewing issues that pertain to providers and members, including the investigation of potential fraud and abuse cases.

 

Audits and reviews of provider claims include, but are not limited to, appropriate coding procedures, appropriate supporting documentation for claims, and any ordered tests or other procedures, retention of medical records and supporting documentation, excessive charges, documented benefits and exclusions, pre-authorization requirements, timeliness of claims submissions, panel vs. non-panel status and reimbursements, member eligibility, and any other appropriate reviews.

SelectHealth believes that a strong and proactive fraud and abuse effort is critical to the success of SelectHealth, and in the best interests of all its members and therefore, is very supportive of the SIU and its efforts to detect fraud and abuse in its many forms.

 

FRAUD AND ABUSE OVERSIGHT AND PROTECTION PROGRAM

 

All referrals to the SIU are reviewed and investigated where appropriate, and subsequently, all pertinent referrals are provided to the SIU Steering Committee, which then makes a determination as to whether or not the information needs to be reported to the State Insurance Fraud Division, under the guidelines of the State Mandatory Reporting laws.

 

The Steering Committee is composed of representatives from Executive Management and from various departments throughout SelectHealth who have been given the mandate of ensuring that SelectHealth is in compliance with the State Mandatory Reporting Act and with SelectHealth’s own policies and procedures.

This committee oversees the fraud and abuse efforts of SelectHealth and ensures those efforts are appropriate and within established guidelines and applicable laws.


 

MANDATORY REPORTING OF FRAUD OR ABUSE

 

SelectHealth has an established policy for reporting insurance fraud to the State Insurance Fraud Division, as required by the state mandatory reporting law. This policy requires all SelectHealth employees to report to their immediate supervisor, the SelectHealth Compliance Department, or the SelectHealth SIU, any situations wherein the employee has a good faith belief that a fraudulent insurance act is being, will be, or has been committed. This good faith belief may also include situations that appear to be acts of insurance abuse, which will also be considered by the SIU. All referrals to the SIU are investigated, and subsequently, all pertinent referrals are provided to the SIU Steering Committee, which will then make a determination as to whether or not the information needs to be reported to the State Insurance Fraud Division.

 

The Steering Committee is composed of representatives from Executive Management and from various departments throughout SelectHealth who have been given the mandate of ensuring that SelectHealth is in compliance with the State Mandatory Reporting Act and with SelectHealth’s own policies and procedures.

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