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Fraud, Waste & Abuse
HealthPlus Corporate Compliance ProgramReporting Fraud Waste & Abuse The Fair and Accurate Credit Transaction Act: Red Flag Rules

HealthPlus Corporate Compliance Program

HealthPlus of Michigan and its subsidiaries has a license to run an HMO and PPO. We also have a Medicare and Medicaid contract. Laws regulate the health care benefits provided by HealthPlus of Michigan. HealthPlus workers, members, providers, and first-tier, downstream, and related entities must follow these laws. HealthPlus must report all fraud, waste, and abuse.

Abuse

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

This definition pertains to all product lines, with the exception of Medicare, Medicare Part D, MIChild and County Health Plan-Plan A. 

Abuse (MIChild Definition) provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the MIChild 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 MIChild program.

Abuse (Medicare & Medicare Part D) includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.

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

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 (42 CFR 455.2).

This includes, but is 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 Attachment A).

This definition pertains to all product lines (including MIChild), with the exception of Medicare, Medicare Part D and County Health Plan - Plan A. 

Fraud (Medicare & Medicare Part D) is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. 18 U.S.C. § 1347.

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).

Waste

Waste (Medicare & Medicare Part D) is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Other Compliance Issues

Other Compliance Issues shall pertain to all issues which violate state or federal laws and regulations or HealthPlus policies and procedures that do not fall within the definition of fraud, waste, or abuse, nor privacy or security.

Reporting Fraud, Waste & Abuse

To report a questionable compliance practice, call the confidential HealthPlus Hotline (1-888-706-1504), submit a report to the confidential reporting website (healthplushotline.ethicspoint.com) or call or write the HealthPlus Compliance and Privacy/Security Official, Theresa Schurman, (810) 720-8199; 2050 S. Linden Road, Flint, Michigan 48532. Reporting can be anonymous and without fear of retaliation or retribution.
 

  • For Medicaid, MIChild or County Health Plan fraud, waste, and abuse, you may contact the Office of Health Services Inspector General at 1-855-MI-FRAUD (643-7283) or write to them at PO Box 30479, Lansing, MI 48909 or www.michigan.gov/fraud.
  • For Medicare or Medicare Part D, you may contact the Office of Inspector General (OIG) of Health and Human Services at 1-800-447-8477, or (for Medicare) the Medicare Recovery Audit Contractor (RAC) and for Medicare Part D, you may contact the Medicare Part D Medicare Drug Integrity Contractor (MEDIC) - (Contact Compliance & Privacy/Security Official or the CMS website (www.cms.hhs.gov) for current address/contact information).
  • For individuals within the Federal Employees Health Benefit Program (FEBHP), you may call the OPM Office of the Inspector General, Insurance Fraud at (202) 418-3300 or write to them at 1900 E Street NW Room #6400, Washington, DC 204015-0001 or email them at OIGHotline@opm.gov.

Fraud, waste, 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, Waste, & Abuse

Member/Beneficiaries

  • Changing, forging or altering 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
  • Misrepresentation of eligibility status
  • Identity theft
  • Prescription diversion and inappropriate use
  • Resale of medications on the black market
  • Prescription stockpiling
  • Doctor shopping

Prescriber/Provider

  • 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
  • Script mills
  • Falsifying information (not consistent with medical record) submitted through a prior authorization or other formulary oversight mechanism in order to justify coverage
  • Remuneration for prescription drug-switching

HealthPlus Employee

  • 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

HealthPlus of Michigan as Sponsor

  • Failure to provide medically necessary services
  • Inappropriate enrollment/disenrollment
  • Improper bid submissions
  • Payments for excluded drugs
  • Inaccuracies in eligibility or coordination of benefits
  • Incorrect calculation of TrOOP
  • Failure to disclose rebates, discounts or price

HealthPlus of Michigan as PBM

  • Inappropriate formulary decisions
  • Pressuring prescribers to change medications
  • Shorting medications - PBM-owned mail order Pharmacies
  • Drug switching - PBM-owned mail order pharmacies
  • Failure to offer negotiated prices

Pharmaceutical Manufacturer

  • Inappropriate documentation of pricing information
  • Kickbacks, inducements and other illegal remunerations
  • Inappropriate relationships with prescribers
  • Illegal off-label promotion
  • Illegal use of samples

Wholesalers

  • Counterfeit and adulterated drugs through black market purchase
  • Diverting drugs
  • Inappropriate documentation of pricing information

Pharmacy FWA

  • Inappropriate billing practices
  • Billing multiple payers for the same prescription
  • Billing for brand when a generic is dispensed
  • Billing for prescriptions that are never picked up
  • Inappropriate use of D.A.W. codes
  • Billing for non-existent prescriptions
  • Billing non-covered items as covered items
  • Drug diversion
  • Prescription drug shorting
  • Bait and switch pricing
  • Dispensing expired or adulterated prescription drugs
  • Prescription refill errors
  • TrOOP manipulation
  • Illegal remuneration schemes
  • Failure to offer negotiated prices

The Fair and Accurate Credit Transaction Act: Red Flag Rules

The Red Flag Rule requires financial institutions (an institution that extends credit) and creditors to develop a program to identify, prevent, and mitigate identity theft. Compliance with the Rule was effective November 1, 2009. Health care providers who extend credit to their patients are required to comply with these rules.

“Red Flags” are described as relevant warning signs of identity theft. These may include:

  • unusual account activity,
  • fraud alerts on a consumer report, or
  • attempted use of suspicious account application documents.

 

As a member, you may be required to provide picture identification when going to a physician’s office, lab, or an emergency room.

You can protect yourself from identity theft by looking for and reporting the following:

  • You receive a bill for another individual.
  • You are billed for a product or service you did not receive
  • You receive a bill from a provider you had not seen
  • You receive a notice of insurance benefits for health services you had not received.

 

If you have identified any of these discrepancies, please call the confidential HealthPlus Hotline at 1-888-706-1504), submit a report to the confidential reporting website (healthplushotline.ethicspoint.com) or call the HealthPlus Compliance Official at (810) 720-8199