Fraud, Waste and Abuse

Health care fraud and abuse is both a state and federal offense. The HIPAA Act of 1996 indicates a dishonest provider or member is subject to fines or imprisonment of not more than 10 years, or both. In addition to fines, probation or incarceration, fraudulent or abusive activities may result in a denial, suspension or termination of the provider’s license under the Michigan Public Health Code or similar action from Medicaid under the Michigan Social Welfare Act. MHP asks providers to partner with us to identify and eliminate fraud, waste and abuse.

What is Fraud, Waste and Abuse?

Fraud is intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable federal and state law (42 CFR § 455.2).

Waste is the overuse of services or other practices that directly or indirectly result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.

Abuse consists of provider practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to the Medicaid program, or commercial health care 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 (42 CFR § 455.2), or commercial health care program.

Examples of fraud, waste and abuse include:

  • Billing more than once for the same service
  • Billing for services never performed or provided
  • Performing inappropriate or unnecessary services
  • Providing lower-cost or used equipment and billing for higher-cost or new equipment
  • Using someone else’s identity altering or falsifying pharmacy prescriptions

Reporting Fraud, Waste and Abuse

To report Commercial fraud, waste and abuse, please contact MHP at 866-866-2135. This can be done anonymously. Additionally, a fraud, waste and abuse claim can be made in writing to:

McLaren Health Plan
Attn: Compliance Officer
G-3245 Beecher Road
Flint, MI 48532
Email: MHPcompliance@mclaren.org

To report Medicaid fraud, waste and abuse via phone, please contact the Medicaid Fraud Hotline at 855-MI- FRAUD (643-7283) or MHP at 866-866-2135. Reports can be made online at michigan.gov/fraud. This can be done anonymously. Additionally, a fraud, waste and abuse claim can be made in writing to:

McLaren Health Plan
Attn: Compliance Officer
G-3245 Beecher Road
Flint, MI 48532
Phone: 866-866-2135
Email: MHPcompliance@mclaren.org

Or

Office of Inspector General
P.O. Box 30062
Lansing, MI 48909

To report Medicare fraud, waste and abuse via phone, contact the OIG Hotline:

Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY: 1-800-377-4950
Fax: 1-800-223-8164
Online: https://oig.hhs.gov/fraud/report-fraud/index.asp

Mail: 
U.S. Department of Health and Human Services
Office of Inspector General 
P.O. Box 23489
Washington, D.C. 20026

McLaren Health Plan
G-3245 Beecher Rd
Flint, MI 48532
ATTN: Compliance Officer
Email: MHPcompliance@mclaren.org

False Claims Act

The Deficit Reduction Act of 2005 requires providing information about both the federal False Claims Act and other laws, including state laws dealing with fraud, waste and abuse and whistleblower protection for reporting those issues.

Federal law prohibits an employer from discriminating against an employee in the terms or conditions of his or her employment because the employee initiated or otherwise assisted in a false claims action. To report a possible violation, please inform your employees they can contact McLaren Health Plan at:

Compliance Hotline – 866-866-2135
Compliance Officer – 888-327-0671

By mail:
McLaren Health Plan
Attn: Compliance Officer
G-3245 Beecher Road
Flint, Michigan 48532

Medicaid:
Office of Inspector General – 855-MI-FRAUD (643-7283)

By mail:
Office of Inspector General
P.O. Box 30062
Lansing, Michigan 48909