Fraud and abuse takes place every day and, without effective controls in place, frequently goes unnoticed. Per Michigan Department of Community Health (MDCH) guidelines, IBA Health Plans (including IBA Health and Life Assurance Company and IBA Self Funded Group, Inc.) has developed a Fraud and Abuse program to identify and prevent Fraud and Abuse.

The Federal Law defines Fraud as 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)

Some possible types of Fraud are:

• Health Care Providers billing for medical or pharmacy services not provided
• Primary Care Physicians (PCPs) discharging members from their care because of the member's health
• Using an expired ID card
• Loaning an ID card to someone else so they can get medical or pharmacy services
• Someone other than you using your ID card
• Changing a prescription
• Giving false information to get medical or pharmacy services

The Federal law defines Abuse as provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an 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 healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (42 CFR §455.2)

Some possible types of Abuse are:

• Going to the emergency room for non-emergent medical services
• Threatening or abusive behavior in a doctor's office, hospital, health plan or pharmacy

Updated 12/20/06