Fraud and Abuse

HealthPlus has a license to run an HMO. We also have a Medicare and Medicaid contract. Laws regulate the health care benefits provided by HealthPlus of Michigan. HealthPlus workers, members and providers must follow these laws. HealthPlus must report all fraud and abuse.  

Fraud is 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* is 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

*This definition pertains to all product lines.

To report fraud or abuse, call the Compliance Hotline at 1-800-345-9956, you do not have to leave your name. You also can write to the Compliance Official, Theresa M. Schurman, Esq., at 2050 S. Linden Rd., P.O. Box 1700, Flint, MI 48501. For the Medicaid program, call the Department of Community Health Program Investigation Section at 1-866-428-0005, write to 400 S. Pine St., Lansing, MI 48909, or click here to access the Medicaid Fraud and Abuse Online Complaint Form, which can be submitted electronically.

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

• Changing a prescription
• Changing medical records
• Changing referral forms
• Letting someone else use your HPM 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 weren’t done
• Billing a balance that isn’t 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
• HMO 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 – HMO does not pay providers