Fraud, Waste, and Abuse

Detecting and Preventing Fraud, Waste, and Abuse

Managed care health plans are responsible for detecting and preventing fraud, waste, and abuse. Amendments to the Balanced Budget Act of 1997 (also known as the Medicaid Managed Care Rules) address or amend assorted managed care policies for Medicaid health plans.

Medicaid managed care fraud means any type of intentional deception or misrepresentation made by an entity or person in a capitated managed care organization (MCO) or other managed care setting with the knowledge that the deception could result in some unauthorized benefit to the entity, himself or herself, or some other person. Medicaid funds paid to an MCO, and then passed on to the subcontractors, are still Medicaid funds from a fraud and abuse perspective. A provider is defined as any individual or entity that receives Medicaid funds in exchange for providing a service (MCO, contractor, or subcontractor).

Fraud can be committed by many entities, including:

• MCOs
• Contractors
• Subcontractors
• Providers
• State employees
• Medicaid beneficiaries and managed care enrollees

The most common types of health care fraud, waste and abuse are:

• Performing unnecessary services to get higher payments
• Up-coding or billing for more expensive services than were actually provided
• Unbundling or billing for services separately to maximize reimbursement
• Using a false diagnosis to get higher payments
• Billing for services never rendered
• Misrepresenting noncovered procedures as medically necessary
• Misuse of a member’s medical identity to obtain health care services

Providers with questions or concerns about fraud, waste, and abuse should contact Upper Peninsula Health Plan (UPHP) Customer Service or the UPHP Compliance Officer. UPHP will not retaliate against anyone reporting in good faith.

How to Report Suspected Fraud, Waste, and Abuse

You may report possible fraud and abuse to:

UPHP Customer Service
853 West Washington Street
Marquette, MI 49855
Call Toll-Free at 1-800-835-2556 (TTY: 711)

UPHP Compliance Hotline
24/7 telephone line that allows internal and external reporting.
906-225-5081

You may also report suspected fraud, waste and abuse directly to the State of Michigan at:

Michigan Department of Health and Human Services
Office of Inspector General
PO Box 30062
Lansing, MI 48909
Call Toll-Free at 855-MI-FRAUD (643-7283)

Or fill out the MDHHS Office of Inspector General Online Complaint Form.
(Clicking on this link will take you away from UPHP’s website)

UPHP Compliance Policies

View UPHP Compliance Policies related to fraud, waste, and abuse, Confidentiality and Standards of Conduct.