Fraud and Abuse

HealthPlus Corporate Compliance Program

Abuse* means 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 recipient practices that result in unnecessary cost to the Medicaid program, as defined in 42 CFR 455.2

Abuse (County Health Plan - Plan A Definition) means provider practices that are inconsistent with sound fiscal business, or medical practices, and result in an unnecessary cost to the Adult Benefits Waiver 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 unnecessary cost to the Adult Benefits Waiver program.

Fraud* means 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, including, but not limited to the Federal False Claims Act, 31 U.S.C 3729-3731 and the Michigan Health Care False Claims Act 323 of 1984 (see Information on False Claims Act).

Fraud (County Health Plan - Plan A Definition) means 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 (42 CR 455.2).

*This definition pertains to all product lines, with the exception of County Health Plan - Plan A.

To report a questionable compliance practice, call the HealthPlus Hotline (800-345-9956 #4 - can be anonymous), or call or write the HealthPlus Compliance and Privacy/Security Official, Theresa Schurman, 810-720-8199; 2050 S. Linden Road, Flint, Michigan 48532. You also can report Medicaid and MIChild fraud and abuse by contacting the Department of Community Health Program Investigative Section at 1-866-428-0005 or write to them at www.michigan.gov/mdch or 400 S. Pine Street, Lansing, MI 48909; you may contact the Centers for Medicaid & Medicare Services at 1-800-447-8477. Fraud and abuse can be reported anonymously and you will not be penalized for filing a complaint with HealthPlus or the federal or state government. 

Examples of fraud and abuse by a member include the following:

• Changing a prescription
• Changing medical records
• Changing referral forms
• Letting someone else use their HealthPlus insurance card to get medical services
• Using transportation services to do something other than go to the doctor.

Examples of fraud and abuse by a provider include the following:

• Lying about credentials such as a college degree
• Billing for services that were not done
• Billing a balance that is not allowed
• Double billing, upcoding, and unbundling
• Collusion among providers – providers agreeing on minimum fees they will charge and accept
• Underutilization – not ordering services that are medically necessary

Examples of fraud and abuse by an employee of HealthPlus include the following:

• Lying about a provider’s credentials or provider network
• Forging a signature on a contract
• Pre- or post-dating a contract
• Intentionally submitting false claims
• Rigging bids – collusion between state employees and HMO employees
• Self-dealing – awarding a contract based solely on friendship or family relationships
• Plan intentionally denies benefits
• Inappropriate incentive plans
• Inappropriate cost-shifting to carved out services
• Embezzlement or theft
• Excessive salaries and fees to close associates of HMOs
• Bust-outs – Plan does not pay providers