Abuse: Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs to the Medicaid Program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards or agreement obligations for health care in a managed care setting.
Compliance- Compliance efforts are fundamentally designed to establish a culture within an organization that promotes the prevention, detection and resolution of instances of conduct that do not conform to federal and state law, or to federal healthcare program requirements.
Fraud- Any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable Federal or State law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting.
HealthChoices Program — The name of Pennsylvania's 1915(b) waiver program to provide mandatory managed health care to Recipients.
Provider — An individual or entity that is engaged in the delivery of medical or professional services, or ordering or referring for those services, and is legally authorized to do so by the Commonwealth or State in which it delivers the services, including a licensed hospital or healthcare facility, medical equipment supplier, or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of the Commonwealth or states in which the entity or person provides services.
Subcontractor — An individual or entity that has a contract with Gateway Health that relates directly or indirectly to the performance of Gateway Health’s obligation under its contract with the Department
Waste — The overutilization of services or other practices that result in unnecessary costs.
Email: [email protected]
Call Gateway Health Hot Line (calls may be anonymous): (412) 255-4340 or 1-800-685-5235
Attn: Director, Medicaid Compliance
Four Gateway Center
444 Liberty Avenue, Suite 2100
Pittsburgh, PA 15222-1222