Help Stop Fraud and Abuse

 

Fraud occurs when someone intentionally misstates facts in order to secure some benefit for themselves or others. Wasteful practices or things that cost the health plan more money than they should are considered abuse.

 

Physicians Health Plan (PHP) has a program to help stop fraud and abuse.

 

Fraud or abuse can be committed by many different parties, including providers, members, and PHP employees.

 

 Examples of member fraud and abuse include:

 

·       Using an expired PHP ID card

·       Letting a friend or family member use their PHP ID card

·       Changing a prescription

·       Trying to get a refill that is not allowed on a prescription

·       Telling a lie to get medical services

 

Examples of provider fraud and abuse include:

 

·       Billing for services that were not performed

·       Upcoding or double billing

·       Improper utilization (either billing for services that were not medically necessary or not ordering ser-vices that are medically necessary)

·       Lying about a diagnosis in order to ensure health coverage for the patient

 

Examples of employee fraud and abuse include:

 

·       Intentionally submitting false claims

·       Self dealing (referring members only to providers who the employee has a financial relationship with)

·       Intentionally denying benefits

·       Embezzlement or theft

 

Please call the PHP Compliance Hotline at 517.267.9990 if you detect fraud or abuse.  Calls can remain anonymous and confidential. You also can send a letter to:

 

Attn: Compliance Department

Physicians Health Plan

PO Box 30377

Lansing, Michigan 48909-7877

 

Suspicions about fraud and abuse regarding Medicaid patients can be shared with the State of Michigan Medicaid Department directly by calling 866.428.0005 or by sending a letter to:

 

Medicaid Integrity Program Section (MIPS)

Capitol Commons Center Building

400 South Pine, 6th Floor

Lansing, MI 48909

 

Reporting to MIPS can be anonymous and confidential.