Neighborhood has developed an enterprise-wide compliance program to foster a culture of integrity and trust that promotes the prevention, detection and resolution of behavior that is inconsistent with federal and state laws, contractual requirements, corporate policies and procedures and standards of business conduct. Neighborhood’s Compliance Program communicates the company’s expectation that compliance is everyone’s responsibility and all employees and other stakeholders are expected to do the right thing by conducting business with the highest ethical standards and to adhere to federal and state laws, rules and regulations, corporate policies and procedures and established standards of conduct governing business activities.
Fraud, Waste and Abuse
Neighborhood has an obligation to report known or suspected fraud, waste and abuse. We use the terms “fraud”, “waste” and “abuse” defined below as applied to our business.
Fraud is a crime that involves 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. Fraud is punishable by imprisonment and/or fines and can result in the exclusion of individuals and organizations from participation in government health care programs, such as Medicare and Medicaid. Exclusion means that you could be barred (i.e., not able to work for any company in the health care industry that contracts for government health care programs) for a number of years or permanently.
Waste includes overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to a government healthcare program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Waste can result in fines and other penalties.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs to a government health care program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Typically, situations categorized as abusive may be characterized as inconsistent with accepted medical or business practices, or which are improper or excessive. Abuse includes provider practices that are inconsistent with sound fiscal, business, or medical services that are not medically necessary or that fail to meet professionally recognized standards of health care. It also includes member practices that result in unnecessary cost to a government healthcare program resulting in increased costs or utilization of medical services or products. Abuse can result in fines and other penalties.
If you suspect fraud, waste or abuse, please call the Compliance Hotline at 1-888-579-1551.