Fraude, malgasto y abuso
Health care fraud, waste and abuse affects each and every one of us. It is estimated to account for 3-10% of the annual expenditures of health care in the United States. It is important for members and providers to know what health care fraud, waste and abuse is, how to spot it and methods to report it.
Definitions of Fraud, Waste and Abuse
"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 Medicare 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 Medicare program.
"Waste" involves taxpayers not receiving reasonable value for money in connection with any government-funded activities due to an inappropriate act or omission by someone with control over or access to government resources. (e.g., executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight.
Some examples of fraud, waste and abuse are:
- A health care provider who bills for services that were never received
- A supplier that bills for equipment or supplies that were never received
- Someone uses another person's MeridianCare card to receive services covered by Medicare
- A health care provider who bills for services more than once when only one service was provided
- Someone alters a prescription that was written by their doctor
- A health care provider or supplier that offers money or gifts as an incentive to receive healthcare services that are not medically necessary
- Someone makes false statements to receive medical or pharmaceutical services
Reporting Fraud, Waste and Abuse
MeridianCare strongly encourages members and requires providers to report all cases of suspected fraud, waste and abuse. If you know of any MeridianCare members, or providers, hospitals, or pharmacies who you suspect have committed fraud, waste or abuse, you can report them using the process described below. You may report anonymously if you choose.
Reporting to MeridianComplete:
If you believe you have seen any fraud, waste or abuse activities, you can contact us immediately at 1-855-323-4578 (TTY 711), Monday - Sunday, 8 a.m. to 8 p.m. We will conduct a thorough investigation and work with State and Federal government agencies to make sure your rights and services are protected to the fullest extent.
You may also report anonymously 24 hours a day 7 days a week at 1-866-364-1350 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m.
Reporting to the Department of Health and Human Services:
Michigan Department of Health & Human Services Office of Inspector General (OIG)
Toll Free Phone: 855-MI-FRAUD (643-7283)
Office Hours: Monday – Friday, 8 a.m. to 5 p.m.
Address: Office of Inspector General
PO Box 30062
Lansing, MI 48909
U.S. Department of Health and Human Services Office of Inspector General (OIG)
Phone:1-800-HHS-TIPS (447-8477)
Fax: 1-800-223-8164
TTY: 1-800-377-4950
Address: US Department of Health and Human Services
Office of Inspector General
ATTN: OIG HOTLINE OPERATIONS
PO Box 23489
Washington, DC 20026
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 Corporate Compliance Officer at 1-844-667-3560 (TTY 711).
Resources
There are many resources available to help you stay informed of fraudulent activities and give you tips on how to protect yourself from them. This is just a short list of some of these resources.
- Report Fraud & Abuse: This government website provides information on Medicare fraud, including examples and how to detect and report them.
- Identity Theft: This government website provides information on identity theft and how to recover from it.
- 4R (PDF): This government document provides tips on how to spot Medicare fraud.
- Protecting Yourself & Medicare from Fraud (PDF): This government document provides tips on how to spot Medicare fraud.
- Quick Facts about Medicare Plans & Protecting Your Personal Information (PDF): This government document provides information on inappropriate Medicare health plan activities.
- US Department of Justice: This government website provides news and updates on national health care fraud.
- Office of Inspector General: This government website provides news and updates on national health care fraud.