Complaint / Grievance

Complaint: Any oral or written expression of dissatisfaction by a consumer submitted to the Managing Entity or to a state agency. Complaints are investigated immediately and documented in a shared and secure server folder with continued follow-up to ensure quick resolution. Possible subjects for complaints include, but are not limited to, the quality of care, the quality of services provided, aspects of interpersonal relationships, failure to respect the consumer ‘s rights, Managing Entity administration, claims practices or provision of services that relate to the quality of care rendered by a provider pursuant to the Managing Entity‘s Contract. A complaint is an informal component of the grievance system.

Grievance: An expression of dissatisfaction about any matter other than an action that cannot be resolved promptly. Possible subjects for grievances include, but are not limited to, violation of consumer rights, quality of care, the quality of services provided and aspects of interpersonal relationships at a provider level and a Managing Entity failure to protect the consumer’s rights.

To Report a Problem Click Here

Fraud, Waste, and Abuse

Fraud: Knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care 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 health care benefit program. (18 U.S.C. § 1347)

Waste: Overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the system of care.  It is not generally considered to be caused by criminally negligent actions; rather, waste relates primarily to mismanagement, inappropriate actions and inadequate oversight.

Abuse: Involves behavior that is deficient or improper when compared with behavior that a prudent person would consider reasonable and necessary business practice given the facts and circumstances. Abuse also includes misuse of authority or position for personal financial interests or those of an immediate or close family member or business associate. Abuse does not necessarily involve fraud, violation of laws, regulations or provisions of a contract or grant agreement. Payment of incentive and award fees in circumstances where the contractor’s performance in terms of cost, schedule and quality outcomes does not justify the fees is an example of contracting waste. In comparison, an example of contracting abuse would include making procurement or vendor selections that are contrary to existing policies or unnecessarily extravagant or expensive.

Some examples of fraud, waste and abuse may involve:

• Contract Fraud and Mismanagement
• Conflict of Interest
• Misuse of Position or Property
• Improper use of Public Funds
• Violations of Law, Rule, or Procedure
• Inappropriate Acts and/or Omission that results in client injury, abuse, neglect or death
• Inappropriate Billing

To Report a Problem Click Here