Help protect yourself from fraud!

Healthcare fraud, waste, and abuse affects all of us. It impacts the quality of health care and results in higher medical and prescription costs. There are many different types of fraud, waste, and abuse. It is important to be able to identify these issues and know what to look for to protect yourself from identify theft and benefit fraud.

Be suspicious of:

• People trying to sell you healthcare items or services door-to-door or over the phone.
• People who offer money or gifts for health care services.
• People offering you free gifts or services in exchange for your Medicare ID number or health plan ID number.
• Shipments of medical supplies you did not order.
• Providers who tell you the item or service is not usually covered, but they “know how to bill” so insurance will pay.

Remember, if it seems too good to be true, it probably is.

Below are some other things you should be aware of to protect yourself from fraud, waste, and abuse.

Online theft of personal information:

• People may try to steal your personal or Medicare information online. They can harm you financially. They may also disrupt your healthcare benefits.
• It’s not always easy to tell the difference between an important email about your benefits and an online scam. An email may say there is a problem with your account. Or it may ask for updated information to continue your healthcare coverage. When in doubt, give us a call at the Member Services number on your Id card. Where here to help.

Telemarketing scams:

• Many legitimate businesses use telemarketing. But criminals can also use live or recorded calls to try to steal your identity. Medicare will not call to ask for your bank account number, Social Security Number, Medicare ID number or health plan ID number and neither will Solis.

To protect yourself:

• Hang up on recorded messages that ask you to verify your personal information.
• Don’t press any keys or numbers when prompted – even if it’s to take your name off their list.
• Never give your personal information to someone you don’t know.
• Report suspicious numbers to the Federal Trade Commission.

Things you can do to protect yourself and your benefits against fraud:

• Never give out your Social Security, Medicare ID number, health plan ID number or banking information to anyone you don’t know. You should only provide this information to people you know should have it.
• Know who you’re sharing your personal information with.
• When you receive a bill for services review it carefully
  • Make sure you received the services or items.
  • Check the number of services or items on your bill or explanation of benefits.
  • Be sure the same service isn’t on your bill more than once.
  • Verify the copayment amount is correct.
• If you think a charge is incorrect and you know the provider, you may want to call their office to ask about it. The person you speak to may help you better understand the services or supplies you got. Ask about the services you receive, such as: Why are they needed?
• Or, your provider may realize a billing error was made.
• Delete or ignore suspicious emails. Don’t click or download attachments you aren’t expecting. Legitimate email addresses usually end in .com, .org or .gov.
• If you are unsure about the information you have received about your benefits, please call our Member Services department at the number on your Solis ID card.

Report concerns to us:

If you see something suspicious or have a question about your plan statement or benefits, call our Member Services department at the number on your ID card. You may also report your concerns anonymously by calling the Compliance Hotline toll-free at 833-720-0006 (USA and Canada only) available 24 hours a day and 7 days a week provided by LightHouse Services.

You can also report suspected fraud or abuse directly to Medicare. Call the Medicare fraud tip line at 1-800-HHS-TIPS (1-800-447-8477). The TTY number is 1-800-377-4950. Email: You can also send up to 10 pages describing the incident to HHSTips@oig.hhs.gov.

The Solis Health Plans, Inc. (HMO) Quality Improvement Program (QI) represents a comprehensive, integrated, and on-going system designed to objectively and systematically monitor and evaluate the quality and appropriateness of clinical and non-clinical care and services provided to Solis Medicare enrollees.

The Solis Quality Improvement Program (QI) is organized to ensure 1) enrollees' access to quality care, 2) on-going monitoring of appropriate utilization of services, and 3) continuous evaluation and improvement in the quality of care and services delivered by participating providers to Solis enrollees. The goals of the Program are to:

• Improve and maintain enrollee’s physical and emotional status.
• Promote health and early intervention and empower enrollees to develop and maintain healthy lifestyles.
• Involve enrollees in treatment and care management decision-making.
• Ensure that the care and treatment provided to enrollees are based on accepted evidenced-based medical principles, standards, and practices.
• Be accountable and responsive to enrollee concerns and grievances.
• Utilize technology and other resources efficiently and effectively for enrollee welfare.
• Ensure that appropriate care and treatment is accessible to enrollees and provided in a timely manner.
• Promote operational excellence and maximize the effective use of resources.

Specific to Medicare Advantage Quality Improvement Program Goals

Solis has an ongoing Quality Improvement Program (QI) for each of their plans. The purpose of a QI Program is to ensure that the Plan has the necessary infrastructure to coordinate care, promote quality, performance, and efficiency on an ongoing basis. The requirements for the QI Program are based on regulation at 42 CFR§ 422.152. It must:

1. Develop and implement a chronic care improvement program (CCIP) 42 CFR §422.152(c);
2. Develop and implement a quality improvement project (QIP) 42 CFR §422.152(d);
3. Develop and maintain a health information system (42 CFR §422.152(f)(1));
4. Encourage providers to participate in CMS and HHS QI initiatives (42 CFR §422.152(a)(3));
5. Establish written policies and procedures that reflect current standards of medical practice, 422.152(b)(1);
6. Implement a program review process for formal evaluation of the impact and effectiveness of the QI Program at least annually (42 CFR §422.152(f)(2));
7. Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms (42 CFR §422.152(f)(3));
8. Mechanism to detect both underutilization and overutilization of services, 422.152 (b)(2);
9. Contract with an approved Medicare Consumer Assessment of Health Providers and Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare enrollees (42 CFR §422.152(b)(5)); and,
10. Measure performance under the plan using standard measures required by CMS and report its performance to CMS (42 CFR §422.152(e)(i)).
11. Develop, compile, evaluate, and report certain measures and other information to CMS, its enrollees, and the general public. Responsible for safeguarding the confidentiality of the doctor-patient relationship and report to CMS in the manner required cost of operations, patterns of utilizations of services, and availability, accessibility, and acceptability of Medicare approved and covered services (42 CFR §422.516(a)).

The Solis Quality Improvement Program (QA/PI) is designed in compliance with Sections of Chapter 641 of the Florida Statutes, the Medicare Managed Care Manual (Chapter 5), and the standards and guidelines established by the Accreditation Association for Ambulatory Health Care (AAAHC), the National Committee for Quality Assurance (NCQA), and the Quality Improvement System for Managed Care developed by the Centers for Medicaid and Medicare Services. The core components of the Program include:

1. An organized structure within Solis with dedicated lines of responsibility and authority for overseeing quality assurance and performance improvement functions. This structure includes the allocation of sufficient resources to implement the wide range of activities associated with effective quality assurance monitoring and performance improvement, including resources for systematically identifying and addressing quality problems and issues, utilization of clinical and non-clinical performance outcome indicators to track change, and mechanisms for implementing remedial and corrective actions with regard to identified clinical and non-clinical problems and issues.
2. Opportunities for on-going provider and enrollee involvement in the Quality Improvement Program and process, facilitated through participation in organization wide oversight committee activities, advisory council participation, and focus groups. Provider involvement is further enhanced through the process or mechanism by which information received from providers is validated, ensured to be complete, compliant with laws/regulations, and made available to CMS upon request.
3. Procedures for monitoring provider and staff understanding, acknowledgement and adherence to Solis member rights and responsibilities, including, the right to choose a primary care physician, to have access to medical records, and to be informed of treatment options and consequences.
4. Procedures and chart review protocols for monitoring provider adherence to specifications for medical record documentation—including what is recorded and how records are stored and retrieved. These procedures are designed to protect enrollees' rights to privacy and confidentiality and serve as a base for monitoring the continuity of care provided to them.
5. Procedures and reporting formats for tracking and trending enrollee grievances and complaints regarding the quality of care and service provided, and adverse organizational determinations regarding the provision of care and service.
6. Methods and protocols for monitoring provider compliance with established standards of availability and accessibility to care, including enrollee access to routine, urgent, and emergency care, to telephone appointments, to advice, and to member services lines.
7. Methods, procedures and reporting formats for monitoring utilization patterns and identifying areas of care and treatment that are over-utilized or under-utilized, including comparative analyses with public data use files.
8. Systematic chart review and monitoring of provider adherence to preventive health screening and assessment criteria.
9. Methods and procedures for monitoring special programs, including the Solis Disease Management Program, Solis Health Risk Management Program, and the Solis Education/Wellness and Lifestyle Management Program.
10. Methods and procedures for on-going assessment of Plan performance utilizing standardized outcome performance measures and methodologies (i.e., HEDIS® recording and reporting as well as STARS), including comparative analyses with corresponding state and federal public data use files.
11. Methods and procedures for systematic assessment of enrollee satisfaction with the care and service provided including, but not limited to, administration of the CAHPS® survey instrument and Health Outcome Surveys (HOS®).
12. Processes for identifying, developing, and implementing special clinical and non-clinical projects and studies related to quality assurance and performance improvement.
13. Methods and procedures for monitoring provider performance in the credentialing process and introducing provider performance evaluations in the re-credentialing process. These policies and procedures are designed to ensure that all enrollees of Solis Health Plans receive care and service from highly qualified and appropriately licensed and certified health care professionals.
14. Development of an annual quality assurance and performance improvement work plan, which includes specification of quality improvement studies, on-going performance monitoring, HEDIS® measurement and SNP MOC submission.
15. Annual review and evaluation of quality assurance and performance improvement program description progress.