Total Health Care

Fraud & Abuse

Total Health Care recognizes combating health care fraud is a system wide challenge. Because there is no precise measure of health care fraud, it takes a collaborative effort with provider and members to improve the detection of fraudulent and abusive activities within our Plan. Combating it begins with knowledge and awareness of what is fraud and abuse.

 

Defining Fraud and Abuse:

Fraud is defined as 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.

 

Examples of member fraud may include:

 

  • Loaning or using another person’s Total Health Care ID card to get medical services.
  • Changing or forging an order or prescription, medical record, or referral form.
  • Selling prescription drugs or supplies obtained under healthcare benefits.
  • Providing false information when applying for benefits or services.
  • Using Transportation Services to do something other than going for medical services.
  • “Doctor shopping” for prescriptions.

 

Examples of provider fraud may include:

 

  • Billing for services not provided.
  • Giving false information about credentials such as a college degree.
  • Billing for more services than were actually performed.
  • Billing for duplicate payments.
  • Billing non-covered services as a covered code.
  • Prescription drug switching.
  • Providing services that are not medically necessary.

 


Abuse
is defined as 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.Examples of abuse may include:

 

  • Misusing codes on claim
  • Excessive charges for services or supplies
  • Billing for additional, unnecessary treatment

Laws to Address Fraud, Waste and Abuse

  • False Claims Act (FCA)
    The FCA (31 United States Code [U.S.C.] Sections 3729-3733) protects the Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim to the Federal Government. The “knowing” standard includes acting in deliberate ignorance or reckless disregard of the truth related to the claim. An example is a physician who submits claims for medical services he/she knows were not provided. Civil penalties for violating the FCA may include fines and up to 3 times the amount of damages sustained by the Government as a result of the false claims. There also is a criminal FCA (18 U.S.C. Section 287). Criminal penalties for submitting flees claims may include fines, imprisonment, or both.
    > More Info on THC’s False Claims Policy

  • Anti-Kickback Statute
    The Anti-Kickback Statute (42 U.S.C. Section 1320a-7b(b)) makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Where remuneration is paid, received, offered, or solicited purposefully to induce or reward referrals of items or services payable by a Federal health care program, the Anti-Kickback Statute is violated. If an arrangement satisfies certain regulatory safe harbors, it is not treated as an offense under the statute. The safe harbor regulations are set forth at 42 Code of Federal Regulations (CFR) Section 1001.952. Criminal penalties for violating the Anti-Kickback Statute may include fines, imprisonment, or both.

  • Physician Self-Referral Law (Stark Law)
    The Physician Self-Referral Law (Stark Law) (42 U.S.C. Section 1395nn) prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or an immediate member of his or her family) has an ownership/investment interest of with which he or she has a compensation arrangement, unless an exception applies. Penalties for physicians who violate the Physician Self-Referral Law (Stark Law) include fines as well as exclusion from participation in all Federal health care programs.

  • Criminal Health Care Fraud Statute
    The Criminal Health Care Fraud Statue (18 U.S.C. Section 1347) prohibits 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, any health care benefit program; in connection with the delivery of or payment for health care benefits, items, or services. Proof of actual knowledge or specific intent to violate the law is not required. Penalties for violating the Criminal Health Care Fraud Statute may include fines, imprisonment, or both.

    Fraud and abuse activities can range from solo to broad-based operations by an institution or group. Anyone can be in violations of these laws. It is important for providers and members to engage in preventing, detecting, and reporting fraud and abuse.

    Additional information regarding Fraud, Waste, and Abuse is available on the HEAT website which you can access through our website at

    http://oig.hhs.gov/compliance/provider-compliance-training/index.asp

    The HEAT webpage provides information videos, audio podcasts and materials related to health care fraud prevention.

Report Suspected Fraud, Waste and Abuse

If you have any information about fraud, waste and abuse, please contact Total Health Care. It is not required that you give us your name. Retaliation for good faith reporting is strictly prohibited. Notification of suspected fraud, waste and abuse can be made anonymously. Reports can be made by calling, writing, faxing or emailing Total Health Care at:

 

Total Health Care
Attn: Fraud and Abuse Coordinator
3011 W. Grand Blvd., Suite 1600
Detroit, MI 48202

 

Call: (800) 826-2862 or (313) 871-2000
Fax: (313) 748-1397

 

Email: eliminatefwa@thcmi.com

 


 

You may also report instances of fraud and abuse directly to the Office of State Health Inspector General without giving your name. You may call the office at (855) 643-7283 or (855) MIFRAUD or send a memo or letter to:

 

Michigan Department of Health and Human Services
Office of Inspector General
PO Box 30062
Lansing, MI 48909-7979

email: MDHHS-OIG@michigan.gov

or

online: http://www.michigan.gov/fraud