Priority Health compliance policy

Priority Health requires all parties that work with us to comply with all laws and regulations. This policy ensures that providers, contractors and vendors are aware of applicable federal and state laws designed to prevent and detect fraud, waste and abuse. In addition, this policy provides information about whistleblower protections.

Compliance training and information

The reputation for excellence and integrity at Priority Health is built on the hard work and responsible conduct of the thousands who have worked with and for us over many years. Our Compliance Program and Code of Excellence shape this culture of compliance. Our Compliance Program and Code of Excellence apply to you as an important business partner. The two documents are provided below for your review.

Medicare training

The Centers for Medicare and Medicaid Services require all health care providers offering services to Medicare plan members to complete an annual training session on how to recognize and prevent fraud, waste and abuse. CMS created two presentations that, when you review them, complete your obligation for this training.

Priority Health Policy: Federal and State Laws Related to Fraud, Waste and Abuse

Policy number: 167-4

Federal and State False Claims Acts

As required by the federal and state False Claims Acts, all providers, contractors and vendors are prohibited from knowingly presenting (or causing to be presented) to the federal or state government a false or fraudulent claim for payment or approval. The acts define "knowingly" to mean a person that has actual knowledge of the false claim, acts in deliberate ignorance of the truth or falsity of the information, or acts in reckless disregard of the truth or falsity of the information. All individuals are prohibited from knowingly making or using (or causing to be made or used) a false record or statement to get a false or fraudulent claim paid or approved by the federal or state government or its agents. The False Claims Acts are enforced against any individual/entity that knowingly submits (or causes another individual/entity to submit) a false claim for payment to the federal or state government. Violation of the Federal False Claims Acts can result in civil penalties from $10,781* to $21,563* per claim. Priority Health monitors the compliance of our contractors and subcontractors to the False Claims Acts.

The federal and state False Claims Acts permit individuals with knowledge of fraud against the federal or state government to file a lawsuit on behalf of the government against the individual/entity that committed the fraud. If the lawsuit is successful, the individual is entitled to a portion of the government's recovery. The False Claims Acts provide a "whistleblower" protection.

*These adjusted amounts will apply only to civil penalties assessed after August 1, 2016, for violations that occurred after November 2, 2015.

Whistleblower

The False Claims Acts include specific provisions to protect whistleblowers from retaliation by their employers. Any private party who initiates or assists with the federal False Claims Act case against his/her employer is protected from discharge, demotion, suspension, threats, harassment and discrimination in the terms and condition of his or her employment if the employer's actions are taken in response to the employees efforts on the case. A private party who does suffer retaliation for his or her assistance with a case against his/her employer is entitled to reinstatement, two times the amount of back pay, interest and compensation for special damages including attorney's fees.

Anti-Kickback Statute

As required by the Anti-Kickback Statute, individuals are prohibited from knowingly or willfully offering, paying, soliciting or receiving remuneration (the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind) in order to induce and reward business payable (or reimbursable) under the Medicare or other federal health care programs. A criminal sanction may place those in violation of the law in jail for up to 5 years, assess a $25,000 fine and impose mandatory exclusion from the participation in any government funded health care programs. On the civil side, the monetary penalty of $50,000 per violation and treble damages that equal three times the dollar amount the government is defrauded may apply.

There are three objectives behind the federal anti-kickback law.

  • To prevent over-utilization of health care programs
  • To limit patient steering
  • To promote market competition

The Program Fraud Civil Remedies Act

The Program Fraud Civil Remedies Act of 1986 provides for administrative remedies against any person who makes, or causes to be made, a false claim or written statement to certain federal agencies, including the Department of Health and Human Services. The Program Fraud Civil Remedies Act addresses lower dollar fraud and generally applies to claims of $150,000 or less.

Stark Law

The Stark law pertains to physician referrals under both Medicare and Medicaid and states that a physician cannot refer patients to an entity for the purpose of furnishing certain designated health services if the physician or an immediate family member has a financial relationship with that entity. The entity cannot bill for improperly referred services unless an exception or safe harbor applies. It is essential to realize that the Stark law has no state-of-mind requirement. The intention and motives of the parties involved are irrelevant. If statutory requirements are met, there is a violation, unless an exception or safe harbor applies.

The Stark law is targeted against over-utilization and improper patient steering, and is intended to increase market competition. Sanctions and fines are civil and criminal penalties do not apply. Under the civil penalty, the entity that did the billing must refund the payments for improperly referred services. There is also a civil monetary penalty of up to $15,000 for any person who presents or causes a claim for improperly referred designated health services as long as they know that the claim is improper.

Reporting

You may report any potential case of fraud, waste or abuse related to Priority Health programs directly to Priority Health or to the government. See details below.

Reporting directly to Priority Health

Report any potential case of fraud, waste or abuse related to Priority Health programs, including Priority Medicare and Priority Medicaid, may be reported to:

  • Customer Service at 616.942.1221 or 800.446.5674
  • Priority Health Compliance Helpline at 800.560.7013 (available 24 hours a day)
  • Fax to 616.942.7916
  • Write to:
    Priority Health Fraud, Waste and Abuse Program
    Special Investigations Unit (SIU) - Mail Stop 3175
    1231 East Beltline NE
    Grand Rapids, MI 49525
You do not have to give your name. You may remain anonymous.

Reporting Medicaid fraud to the State of Michigan

You may also report suspected cases of fraud related to Priority Health Medicaid directly to the State of Michigan Medicaid department through any of these contact methods:

You do not have to give your name. You may remain anonymous. Reporting Medicare fraud to Office of Inspector General

Report suspected cases of Medicare fraud to the Office of Inspector General at:

  • 800.447.8477 (toll-free)
  • Write to:
    Office of the Inspector General
    Department of Health and Human Services
    P.O. Box 23489
    Washington, DC 20026
You do not have to give your name. You may remain anonymous.

Supporting documentation

Compliance verification

Provider contracts require compliance with all federal and state laws. All contracts are signed.

Reference documentation

  • Section 6032 of the Deficit Reduction Act of 2005
  • MCL 400.601-400.613
  • 31 USC 3729-3733