Compliance with fraud, waste and abuse laws
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.
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 AbusePolicy number: 167-5
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 $5,000* to $10,000* 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.
The federal and state False Claims Acts include specific provisions to protect whistleblowers from retaliation by their employers. Any private party who initiates or assists with a 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.
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.
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.
Under the Exclusion Statute, the Office of Inspector General (OIG) must exclude from participation in all federal health care programs providers and suppliers convicted of:
- Medicare fraud
- Patient abuse or neglect
- Felony convictions related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of a health care item or service; or
- Felony convictions for unlawful manufacture, distribution, prescription or dispensing of controlled substances.
The OIG also has the discretion to impose exclusions on a number of other grounds.
Excluded providers cannot participate in federal health care programs for a designated period. An excluded provider may not bill federal health care programs (including but not limited to Medicare, Medicaid, and State Children’s Health Insurance Programs (SCHIP) for services he or she order or performs. At the end of an exclusion period, an excluded provider must affirmatively seek reinstatement. The OIG maintains a list of excluded parties called the List of Excluded Individuals/Entities (LEIE) on the OIG website.
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, 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
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:
- 1.855.MI-Fraud (855.643.7283) (toll-free)
- michigan.gov online complaint form
- Write to:
Office of the Inspector General
P.O. Box 30062
Lansing, MI 48909
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
Provider contracts require compliance with all federal and state laws. All contracts are signed.
- Section 6032 of the Deficit Reduction Act of 2005
- MCL 400.601-400.613
- 31 USC 3729-3733
- 31 USC 3801-3812
- 42 USC 1320a-7
- 42 USC 1320a-7b(b)
- 2015 Inflation Adjustment Act (Public Law 114-74, Sec. 701)
- Priority Health Compliance Program
- Fraud, Waste and Abuse Manual
* Amounts adjusted annually for inflation as provided under the 2015 Inflation Adjustment Act
- NPI numbers
- Electronic funds transfer (EFT)
- Physician status
- Open or close to new patients
- Availability standards
- Changes to address or staff
- Provider-patient relationship
- Medical & office records
- Medicaid patient treatment
- Medicare patient treatment
- Site visits
- Fraud, waste & abuse
- Utilization Management Program
Learn more about fraud, waste & abuse
See definitions, examples, and reporting information in our Contact us > Preventing/reporting fraud & abuse section.