Help Fight Fraud, Waste and Abuse

Medicaid pays doctors, hospitals, pharmacies, clinics and other health care providers to take care of adults and children who need help getting medical care. Sometimes, providers and patients misuse Medicaid resources. This leaves less money to help people in our state who need care. This misuse is called fraud, waste and abuse.

What are fraud, waste and abuse?

Fraud means an intentional deception or misrepresentation made by a person who knows that the deception could lead to his or her benefit. Or, it could lead to the benefit of someone else. It includes any act of fraud under federal or state law.

Example of Fraud

Sam’s pharmacy bills Medicaid for a medication that Sam didn't receive. The pharmacy knew Sam did not receive the medication. But, the pharmacy sent a bill for the medication anyway.

This is an example of fraud because the pharmacy intentionally billed for a medication that was not given to the customer.

Waste is an over use of services, or other practices that lead to unnecessary costs. Waste is not caused by criminal actions. It is caused by the misuse of resources.

Example of Waste

Rachel’s doctor often prescribes an expensive medication for her instead of the less expensive medicine on the drug list.

This is an example of waste because the doctor is prescribing a brand-name medicine rather than the generic medicine. This is waste because there is no medical reason to do so.

Abuse means provider actions that don't follow appropriate fiscal, business or medical practices. This leads to an unnecessary cost to the Medicaid program. It also leads to spending money for services that aren't medically necessary. Abuse includes actions that don't meet professional standards for health care. Abuse also includes a member's actions leading to added cost to the Medicaid program.

Example of Abuse

Jonathan’s doctor asked for x-rays and blood tests and gave a physical exam of Jonathan. But Jonathan only wanted to see the doctor to remove a wart on his finger.

This is an example of abuse because the doctor asked for more tests than what the patient needed.

Why should I care about fraud, waste and abuse?

Fraud, waste and abuse affects members and providers. It can:

  • Raise your taxes
  • Keep providers from being paid for services
  • Lead to rising costs

Fraud is a real crime that can lead to fines or even jail time.

What to look for

Blue Cross Complete of Michigan works to find, investigate and stop fraud. Know what to look for. When you get a bill from your doctor or an Explanation of Benefit statement, make sure:

  • The name of the doctor is the same doctor who treated you
  • The type and date of service are the same type and date of service you received
  • The diagnosis is the same as what your doctor told you

Cutting down on fraud, waste and abuse helps Michigan provide more care and makes the Medicaid program even stronger. Together we can stop fraud.

Tell us about fraud

When you report fraud, waste or abuse, you don't have to leave your name. To make a report, write:

 

Blue Cross Complete Anti-fraud Unit
P.O. Box 018
Essington, PA 19029

You may also report or get more information about fraud from the Michigan Department of Health and Human Services Office of Inspector General.

 

Michigan Department of Health and Human Services Office of Inspector General
P.O. Box 30062
Lansing, MI 48909

When you report fraud to the Office of Inspector General, you don’t have to leave your name. Information may be sent or left anonymously.

Note: Information you share over e-mail is not secure and could be read by a third party. If you are sending information you want to keep private, contact us by telephone, fax or letter.

More Information

For more information about health care fraud, contact the following organizations:

National Health Care Anti-Fraud Association
Phone: 1-202-659-5955
Email: fraud@nhcaa.org

Centers for Medicare and Medicaid Services
Phone: 1-877-267-2323

Michigan Department of Health and Human Services
Phone: 1-517-373-3740