Fraud and Abuse

Health care fraud occurs when people intentionally misrepresent information to secure some benefit for themselves or others. Wasteful and abusive practices, directly or indirectly, result in unnecessary costs, such as performing services that are not medically necessary or submitting claims for services without legal entitlement to that payment.

Anyone can commit healthcare fraud, from individual actions to large-scale institutional schemes, and everyone can help identify and report fraud concerns. University of Michigan Health Plan (UM Health Plan) is dedicated to detecting, investigating, and preventing suspicious activities related to possible health care fraud, waste, and abuse (FWA), including any reasonable belief that insurance fraud will be, is being, or has been committed. Individuals or entities that have committed fraud face potential criminal, civil, and administrative liability, which may lead to imprisonment, fines, and penalties.

Report anonymously and confidentially 24 hours a day, 7days a week by:

1.   Calling the UM Health Plan Compliance Hotline at 866-747-2667

2.   Web reporting at www.MyComplianceReport.com and enter access ID: PYHP

3.   In writing:
Attn: Compliance Department
University of Michigan Health Plan
PO Box 30377
Lansing, MI 48909-7877

4.   Email: Compliance@UofMHealthPlan.org

Examples of Fraud, Waste, and Abuse Include:

·      Billing for services that were not performed

·       Upcoding or double-billing

·       Prescribing drugs, equipment, or services that are not necessary

·       Intentionally submitting false claims

·       Allowing someone who is not employed with, or who does not meet the eligibility requirements for, your company to enroll or remain enrolled as if the person were an employee or met eligibility requirements

·      Sharing insurance card or using someone else’s insurance card to access healthcare

How to prevent FWA

Members can prevent FWA:

·       Review medical bills and explanation of benefits (EOB) to confirm services billed were received.

·       Only share your Social Security number and health insurance information with verified sources.

·       Monitor credit reports

Providers can prevent FWA:

·       Perform internal audits to ensure correct coding

·       Monitor and audit internal policies and procedures

·       Verify patient identity

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