Health Care fraud is both a state and federal offense. Based on the HIPAA regulations of 1996, a dishonest provider or member may be subject to fines or imprisonment of not more than 10 years, or both (18USC, Ch. 63, Sec 1347).

The following are the official definitions of Fraud, Waste and Abuse:

42 CFR §455.2 Definitions.

"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.

"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.

“Waste”  Involves the taxpayers not receiving reasonable value for money in connection with any government funded activities due to an inappropriate act or omission by players with control over or access to government resources (e.g. executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight-From the Inspector General.

To help you identify Fraud, Waste and Abuse, below are examples of both:

Some examples of Fraud are:

• Providers billing for services not provided.
  
• Providers billing for the same service more than once (i.e. double billing).
  
• Providers performing inappropriate or unnecessary services.
  
• The misuse of a Medicaid card to receive medical or pharmacy services.
  
• Altering a prescription written by a doctor.
  
• Making false statements to receive medical or pharmacy services.
  

Some examples of Abuse are:

• Going to the Emergency Room for non-emergent medical services.
  
• Threatening or abusive behavior in a doctor's office, hospital or pharmacy.
  

HPM encourages members, providers and employees to report all cases of Fraud, Waste and Abuse. If you know of any Medicaid members or providers, including doctors, hospitals and pharmacies, who have committed actions of fraud, waste or abuse, you can report them using the process described below. You may report them anonymously if you choose.

To Report Potential Fraud, Waste and Abuse:

Members
Contact HPM's Member Services Department at 1-888-437-0606. Tell them what you know about the possible fraud, waste and abuse. They will file a report on your behalf.

Providers
Contact HPM's Provider Services Department at 1-888-773-2647. Ask to speak with the Director of Provider Services. You can explain details of the possible fraud, waste or abuse and HPM can investigate and file a report with the DCH Program Investigations Section, if necessary.

HPM members, providers or employees can also report potential instances of fraud, waste and abuse directly to the State of Michigan at the following address. You can report anonymously if you choose.

Medicaid Integrity Program Section
Capitol Commons Center Building
400 S. Pine Street 6th Floor
Lansing, MI 48909
1-866-428-0005

HPM members, providers or employees can also report potential fraud, waste or abuse anonymously in writing to Health Plan of Michigan at the following address:

Compliance Officer
Health Plan of Michigan
777 Woodward Avenue, Suite 600
Detroit, MI 48226

Phone: 1-888-437-0606
Fax: 1-313-202-0009

• Medicaid Fraud Complaint Form

The False Claims Act

The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the Government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government's damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud.

The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit on behalf of the Government against the person or business that committed the fraud. The lawsuit is known as a "qui tam" case, but it is more commonly referred to as a "whistleblower" case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer.

For more information on the False Claims Act, please contact the HPM Corporate Compliance Officer at 1-888-437-0606.