HealthPlus of Michigan and its subsidiary have a license to operate an HMO and a PPO. We also have a Medicare Advantage contract with CMS plus the Federal Employee Health Benefit Program (FEHBP). 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 means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicare recipient and Federal Employee; 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 these programs.
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.
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.
This definition pertains to all product lines , with the exception of Medicare, and Medicare Part D.
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.
Waste (Medicare & Medicare Part D) is the over utilization 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 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.
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 Interim Compliance and Privacy/Security Official, Dave Paxton, 1-810-230-2276; 2050 S. Linden Road, Flint, Michigan 48532. Reporting can be anonymous and without fear of retaliation or retribution.
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:
a member, you may be required to provide picture identification when going to a
physician’s office, lab, or an emergency room.
can protect yourself from identity theft by looking for and reporting the
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 1-810-720-8199.
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