Members

Fraud Prevention

fraud

Fraud, Waste and Abuse

Molina Healthcare’s Fraud, Waste and Abuse Plan benefits Molina, its employees, members, providers, payers and regulators by increasing efficiency, reducing waste, and improving the quality of services. Molina Healthcare takes the prevention, detection, and investigation of fraud, waste and abuse seriously, and complies with state and federal laws. Molina Healthcare investigates all suspected cases of fraud, waste and abuse and promptly reports to government agencies when appropriate. Molina Healthcare takes the appropriate disciplinary action, including but not limited to, termination of employment, termination of provider status, and/or termination of membership.

Definition:

“Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (42 CFR §455.2)

Here are some examples of abuse:

  • Using the emergency room for non-emergent healthcare reasons
  • Going to more than one doctor to get the same prescription
  • Threatening or offensive behavior at a doctor’s office, hospital or pharmacy
  • Receiving services that are not medically necessary

Definition:

“Fraud” means an intentional deception or misrepresentation made by a person with the knowledge

that the deception could result in some unauthorized benefit for them or some other person. It includes any act that constitutes fraud under applicable federal or state law.

(42 CFR § 455.2)

Here are some examples of fraud:

  • Using someone else’s member ID card
  • Changing a prescription written by a doctor
  • Billing for services that were not provided
  • Billing for the same service more than once

 

Here are some ways you can help stop fraud:

  • Don’t give your Molina Healthcare ID card, Medical ID Card, or ID number to anyone other than a health care provider, a clinic, or hospital, and only when receiving care
  • Never let anyone borrow your Molina Healthcare ID Card
  • Never sign a blank insurance form
  • Be careful about giving out your social security number


Definition:

“Waste” means health care spending that can be eliminated without reducing the quality of care. Quality Waste includes, overuse, underuse, and ineffective use. Inefficiency Waste includes redundancy, delays, and unnecessary process complexity. For example: the attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, however the outcome of poor or inefficient billing methods (e.g. coding) causes unnecessary costs to the Medicaid/Medicare programs. If you think fraud, waste and abuse has taken place, you can report it without giving your name to:

Online: www.MolinaHealthcare.alertline.com
Email: MHMCompliance@MolinaHealthCare.com
Phone: 1-866-606-3889
Fax: 1-248-925-1797
Regular Mail:
Molina Healthcare of Michigan
Attention: Compliance Director
880 West Long Lake Road, Suite 600
Troy, MI 48098-4504

Or you can contact:

Online: www.michigan.gov/fraud
Phone: 1-855-MI-FRAUD (1-855-643-7283)
Regular Mail:
Michigan Department of Health and Human Services (MDHHS)
Office of Inspector General
P.O. Box 30062
Lansing, MI 48909