Report Fraud, Waste and Abuse
Sunflower Health Plan takes the detection, investigation, and prosecution of fraud and abuse very seriously, and has a fraud, waste, and abuse (FWA) program that complies with the State of Kansas and federal laws. Sunflower, in conjunction with its parent company, Centene, operates a fraud, waste, and abuse unit. Sunflower routinely conducts audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system, please review the Billing and Claims provider manual. The Centene Special Investigation Unit (SIU) performs retrospective audits which, in some cases, may result in taking actions against providers who commit waste, abuse, and/or fraud. These actions include but are not limited to:
- Remedial education and training to prevent the billing irregularity
- More stringent utilization review
- Recoupment of previously paid monies
- Termination of provider agreement or other contractual arrangement
- Civil and/or criminal prosecution
- Any other remedies available to rectify
Some of the most common FWA practices include:
- Unbundling of codes
- Up-coding services
- Add-on codes billed without primary CPT
- Diagnosis and/or procedure code not consistent with the member’s age/gender
- Use of exclusion codes
- Excessive use of units
- Misuse of Benefits
- Claims for services not rendered
If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential FWA hotline at 1-866-685-8664. Sunflower Health Plan and Centene Corporation take all reports of potential waste, abuse or fraud very seriously and investigate all reported issues.