Fraud and Abuse

Help Stop Fraud and Abuse

Fraud occurs when people intentionally misrepresenting information to secure some benefit for themselves or others. Wasteful practices, items or services that cost the health plan more money than they should are considered abuse.

Healthcare fraud is a crime that has a significant effect on the private and public healthcare payment system. Fraud and abuse accounts for more than 10 percent of annual healthcare costs. Taxpayers pay higher taxes because of fraud in public programs such as Medicaid and Medicare. Employers and individuals pay higher private health insurance premiums because of fraud in the private sector healthcare system. 
Recognizing the serious implications of fraud, Physicians Health Plan (PHP) is dedicated to detecting, investigating and preventing all forms of suspicious activities related to possible healthcare fraud and abuse, including any reasonable belief that insurance fraud will be, is being or has been committed.

PHP’s compliance program helps us to detect and prevent fraud, waste and abuse.  Fraud, waste or abuse can be committed by many different parties, including providers, members, employer groups and PHP employees.  You can help prevent FWA by:

• Checking your medical bills and your explanation of benefits (EOB)’s to make sure you were only charged for services
• Never give your Social Security number, health insurance information or banking information to someone you do not know
• Knowing that free services do not require you to give your health insurance identification number to anyone

Examples of Provider Fraud, Waste 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 services that are medically necessary)
• Misrepresenting a diagnosis in order to ensure health coverage for the patient
• Prescribing drugs, equipment, or services that are not necessary

Examples of Employee Fraud, Waste and Abuse Include:

• Intentionally submitting false claims
• Self-dealing (referring members only to providers with whom the employee has a financial relationship)
• Intentionally denying benefits
• Embezzlement or theft

Examples of Group Eligibility Fraud, Waste and Abuse Include:

• Adding an ineligible individual as a dependent (e.g., listing someone as a “spouse” when not married to that individual)
• 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
• Failing to notify PHP or the plan administrator of a divorce and continuing to cover an ex-spouse
• Misrepresenting the date of birth of a dependent in order to meet age-related eligibility requirements

You can report suspected fraud, waste or abuse anonymously and confidentially 24 hours a day, 7 days a week by:

1. Calling the PHP Compliance Hotline at 866.PHPCOMP(747.2667).
2. Webreporting at www.MyComplianceReport.com and enter access ID: PYHP
3. In writing:
   Attn: Compliance Department
   Physicians Health Plan
   PO Box 30377
   Lansing, MI 48909-7877 or
4. Email us at: phpcompliance@phpmm.org