Health care fraud and abuse affects each and every one of us.  It is estimated to account for between 3% and 10% of the annual expenditures for health care in the U.S.

Health care fraud is both a state and federal offense.  Based on the HIPAA regulations of 1996, a dishonest provider or member may be subject to fines or imprisonment of not more than 10 years, or both (18USC, Ch. 63, Sec 1347).

The following are the official definitions of Fraud and Abuse:

42 CFR §455.2 Definitions.
"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.

"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.

To help you identify Fraud and Abuse, below are examples of both:

  • Providers billing for services not provided.
  • Providers billing for the same service more than once (i.e. double billing).
  • Providers performing inappropriate or unnecessary services.
  • The misuse of a Medicaid card to receive medical or pharmacy services.
  • Altering a prescription written by a doctor.
  • Making false statements to receive medical or pharmacy services.
  • Going to the Emergency Room for non-emergent medical services.
  • Threatening or abusive behavior in a doctor's office, hospital or pharmacy.

 

Meridian Health Plan encourages members, providers and employees to report all cases of Fraud and Abuse.  If you know of any Medicaid members or providers, including doctors, hospitals and pharmacies, who have committed actions of fraud or abuse, you can report them using the process described below. You may file a report anonymously if you choose.

To Report Potential Fraud and Abuse:

Contact Meridian Health Plan at 1-866-606-3700 and ask to speak with the Compliance Officer. Tell them what you know about the possible fraud and abuse.  They will file a report on your behalf.

Or write to Meridian Health Plan at the following address:
Compliance Officer
Meridian Health Plan
777 Woodward Avenue, Suite 600
Detroit, MI  48226
Fax: 1-313-202-0009

The False Claims Act
The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the Government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government's damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud.

The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit on behalf of the Government against the person or business that committed the fraud. The lawsuit is known as a "qui tam" case, but it is more commonly referred to as a "whistleblower" case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer.

For more information on the False Claims Act, please contact the Meridian Health Plan Compliance Officer at 1-888-606-3700.