Any suspected fraud or abuse of any Department of Community Health program must be reported to the Program Investigation Section. The Program Investigation Section has responsibility and authority to make all fraud and abuse referrals to the Office of Attorney General, Health Care Fraud Division.

Definitions of Fraud and Abuse

Fraud

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).

Abuse

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 health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program (42 CFR § 455.2).

Reporting Fraud and Abuse

Department Staff

Department of Community Health staff or DCH contractors who suspect the presence of fraud or abuse within any of the Department’s programs MUST report the suspicion DIRECTLY to the Program Investigation Section by calling (866) 428-0005 or sending a memo/letter to:

Any Other Individual

Any individual who suspects the presence of fraud or abuse within any of the Department’s programs may report the suspicion by calling toll-free (866) 428-0005 or sending a memo or letter to:

What Information is Necessary

The following information is necessary when reporting suspected fraud or abuse:

• Nature of the complaint
• The name of the individuals and/or entity involved in the suspected fraud and/or abuse, including their address, phone number and Medicaid identification number, and any other identifying information, if available.

Questions

Questions regarding fraud and abuse should be directed to the Program Investigation Section, P.O. Box 30479, Lansing, Michigan 48909, or by telephone to (866) 428-0005.