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.
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
definition pertains to all product lines, with the exception of Medicare,
Medicare Part D, and MIChild
(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.
(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.
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).
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.
definition pertains to all product lines (including MIChild), with the
exception of Medicare, and Medicare Part D.
(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.
(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.
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.
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.
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.
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
Flags” are described as relevant warning signs of identity theft. These may
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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