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

Fraud and abuse increases taxes and the cost of healthcare. Report any suspected fraud or abuse as soon as possible. To report possible fraud or abuse cases, you may contact IBA Health Plans' Customer Service department at 1-800-851-0404, or by writing to:

IBA Health Plans
P.O. Box 51100
Kalamazoo, MI 49005-1100

You can also contact the State of Michigan Program Investigation Section at 1-866-428-0005, or by writing to them at:

Program Investigations Section
Capitol Commons Building
400 S. Pine St., Sixth Floor
Lansing, MI 48909

You don't have to give your name when you contact IBA Health Plans or the DCH/Program Investigation Section so you can remain anonymous.

View Code of Federal Regulations (CFR): 42 CFR 455.2

Other Resources:
Centers for Medicare & Medicaid Services
Medicaid Fraud & Patient Abuse Complaint Filing Information
Fraud & Abuse Reporting Requirements

Updated 12/20/06