IF YOU ARE AN NOVA PATHFINDER MEMBER WITH A SERVICE, BILLING, COST-SHARE, BALANCE BILLING, GRIEVANCE OR COMPLAINT ISSUE RELATED TO YOUR INSURANCE COVERAGE, PLEASE CONTACT OUR CARE ADVOCATE DEPARTMENT AT 1-833-444-NOVA (6682).
Compliance at Nova Pathfinder Healthcare
Who is Compliance, and what do we do? As part of our Culture of Compliance, everyone at Nova Pathfinder is responsible for understanding and meeting the rules that apply to their work – including our Code of Conduct. To support this goal, the Compliance Department ensures that Nova Pathfinder’s entities, products, and delegates are appropriately monitored and audited for their adherence to the state and federal requirements governing health insurance.
How can you contact Compliance?
The Compliance Department has an open door policy. We welcome all reports of potential or actual noncompliance, ethics concerns, or other wrongdoing. If we are not the right audience for a given report, we will refer it to the appropriate Nova Pathfinder team – but in all cases, those who report concerns in good faith can do so without fear of intimidation or retaliation.
To report a compliance concern, call our Hotline at 1-833-444-6682 or report online from the “Contact Us” page. If you choose, you may make your report anonymously – but because we will not be able to follow up with you, please provide as much detail as possible.
Fraud, Waste, and Abuse (FWA)
How does Nova fight FWA? FWA (defined below) is pervasive in the healthcare industry, and Nova Pathfinder is not immune. Among other things, FWA can negatively impact members’ health, drive up prices, and divert resources from those who need them most.
Within Nova Pathfinder’s Compliance Department, compliance officers are tasked with detecting, preventing, investigating, and resolving FWA in the delivery of healthcare services. Although the Compliance officer relies heavily on data analytics to identify FWA, we also welcome reports of suspected FWA from members, providers, and the public. Each report is investigated and, if a case is substantiated, Nova Pathfinder reports it to applicable state and federal agencies, as well as to local law enforcement.
How can you report FWA?
To reach the compliance department with a report of suspected FWA, call our Hotline at 1-833-444-6682 or report online using the “contact us” form. If you choose, you may make your report anonymously – but because we will not be able to follow up with you, please provide as much detail as possible.
What is Healthcare FWA?
Fraud means knowingly and willfully obtaining, or attempting to obtain (by means of false pretenses, representations, or promises) any money or property owned by, or under the custody or control of, a healthcare benefit program. Fraud can have both civil and criminal implications.
Waste means overutilization of services or other practices that, directly or indirectly, results in unnecessary costs to the healthcare system.
Abuse is the result of practices that are inconsistent with, or outside the bounds of, generally accepted practices in the industry, resulting in unnecessary services and payment.
FWA can take many forms, but some of the more common ones include:
Fraud by providers:
- Submitting claims for services or supplies not provided
- Billing for services completed by a different provider, particularly if unlicensed
- “Unbundling” codes for component parts of a procedure to increase reimbursement
- Improperly using medical codes or code modifiers
- Using covered codes to bill for non-covered services
- Performing medically unnecessary services to obtain reimbursement
Fraud by members:
- Misrepresenting information on insurance applications or facility forms to appear eligible for coverage
- Using someone else’s coverage or insurance card
- Filing claims for services or medications not received
Fraud by businesses:
- Misrepresenting a business to obtain health coverage for individuals
- Adjusting hiring or termination dates to stretch coverage dates
- Improperly enrolling members as primary or dependents who do not qualify
If you have witnessed or suspect FWA, please report it to Nova Pathfinder’s compliance department. (see above).
Please see Nova Pathfinder’s Non-Discrimination Policy for more detail.