Dear Provider:
Total Health Care recognizes combating healthcare fraud is a system wide challenge. It will take a collaborative effort with providers and members to improve the detection of fraudulent and abusive activities within our Plan. Combating fraud and abuse begins with knowledge and awareness of what is fraud and abuse.
Definitions:
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 (42 CFR §455.2).
Abuse 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 (42 CFR §455.2).
Examples of member fraud include:
- Loaning or using another's ID
- Changing or forging an order or prescription
- Selling prescription drugs or supplies obtained under healthcare benefits
- Providing false information when applying for benefits or services
Examples fo provider fraud include:
- Billing for services not provided
- Billing for services not rendered
- Billing for additional, unnecessary treatment
- Billing for duplicate payments
- Unbundling procedures
If you have any information about fraud and abuse, please contact Total Health Care. It is not required that you give us your name. Notification of suspected fraud and abuse can be made anonymously. Reports can be made by calling, writing, or emailing Total Health Care at:
Mail:
Total Health Care
Fraud and abuse Dept
3011 W. Grand Blvd., Suite 1600
Detroit, MI 48202
Call:
(800) 826-2862 or (313) 871-2000
Email:
You can also report suspected Medicaid fraud and abuse, directly, with or without giving your name, to the Medicaid Integrity Program Section by calling (866) 428-0005 or sending a memo or letter to:
Medicaid Integrity Program Section
Capitol Commons Center Building, 6th floor
PO Box 30479
400 S. Pine Street
Lansing, MI 48909-7979
