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As a government contractor, Community Health Network Of Connecticut (CHNCT) recognizes the importance of protecting the integrity of the programs it provides services for.  Both the government and private industry have employed various tools to combat fraud and abuse in healthcare.  CHNCT is committed to identifying, detecting and preventing fraud and abuse in our organization and throughout the healthcare industry.

Fraud and Abuse are defined in the Code of Federal Regulations as follows:

  • Fraud: an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable Federal or State law.
  • Abuse: provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes beneficiary practices that result in an unnecessary cost to the Medicaid program.

Each one of us has a responsibility to be aware of the different types of fraud and abuse that could occur and to report any instance we suspect may involve fraudulent activity

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CHNCT's Policies on Fraud and Abuse, Including False Claims and Statements

CHNCT Providers are expected to adopt CHNCT's policies that address fraud and abuse, including false claims and statements. CHNCT has included detailed information in its policy that addresses: 1) Federal False Claims legislation; 2) procedures for detecting and preventing waste, fraud and abuse; 3) Connecticut state laws pertaining to civil or criminal penalties for false claims and statements involving federal healthcare programs; and 4) whistleblower protections under such laws. To view CHNCT's policies, please click here

Examples of Fraud and Abuse

Committed by Members:

  • Giving an enrollment card to someone who is not eligible for services.
  • Inappropriate utilization of services, such as selling prescription drugs prescribed to them

Committed by Providers/ Practitioners:

  • Improper coding, including upcoding and unbundling.
  • Billing for services that were never rendered.
  • Inflating the bills for goods and/or services provided.
  • Receiving more than one payment for the same service and keeping both payments.

Committed by Health Plans:

  • Knowingly distributing marketing materials, that falsifies plan information.
  • Cherry picking, or selecting the healthiest segment of the enrollment population.
  • Failing to serve individuals with cultural or language barriers.
  • Submitting false data to a government entity.

How Does CHNCT Help Combat Fraud and Abuse?

CHNCT’s Fraud and Abuse Prevention Plan is a component of its Compliance and Ethics Program.   To assist in protecting the integrity of Connecticut’s government programs, CHNCT has taken the following actions:

  • Implemented policies and procedures to address preventing and detecting fraud and abuse;
  • Educated staff on identifying and reporting suspected fraud and abuse;
  • Perform analyses of claims data and medical record reviews to identify and/or investigate potential fraud or abuse occurrences;
  • Periodically educate CHNCT members and providers on fraud and abuse through newsletter articles; and
  • Coordinate with government agencies and/or law enforcement to report and/or assist with investigations of suspected fraud or abuse.

How to Report Suspected Fraud and Abuse

CHNCT has a confidential Compliance Hotline for our employees to report suspected fraud or abuse.  If you become aware of a potential fraud or abuse situation, we encourage you to report the instance to CHNCT’s Government Affairs and Compliance area.  Please call CHNCT’s toll-free Fraud Reporting Hotline at 1-866-700-6109 to report your concerns.  Please provide as much information as possible, including:

  • A detailed description of the activity you are reporting;
  • The name of the individual and/or entity you are reporting;
  • How you came to know about the incident you are reporting; and
  • Contact information for yourself if you would be willing to speak with us again.

The CT Department of Social Services’ (DSS) is also an option for providers/ practitioners to report suspected fraud or abuse involving Connecticut’s government programs, including HUSKY A, HUSKY B and SAGA.  The toll-free number for reporting fraud to DSS is 1-800-842-2155

Links that Provide Information on Fraud and Abuse:
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