Report Fraud

Health care fraud, waste and abuse hurts everyone including members, providers, taxpayers and CareSource. As a result, CareSource has a comprehensive fraud, waste and abuse program in our Special Investigations Department. Help us by reporting questionable situations.

Examples of member fraud, waste and/or abuse include:

  • Sharing ID cards with others
  • Selling prescription drugs or other prescribed equipment to others to make money
  • Changing prescription forms to get more than the amount of medication prescribed by their physician

Please report any member fraud, waster and/or abuse. See the contact information below.

Examples of provider fraud include:

  • Billing for services not provided
  • Billing for unnecessary medical services
  • Up-coding services to receive higher reimbursement
  • Prescribing drugs or services that aren't medically necessary
  • Unbundling CPT codes to obtain higher reimbursement
  • Schedule more frequent return visits than are needed
  • Balance billing Members for services paid at the Medicaid rate

Please avoid these examples of provider fraud, waste and/or abuse.  We routinely monitor our claim data looking for billing aberrancies. When found, an investigation is initiated and if warranted based on investigative findings, a corrective action is taken. Corrective actions can include provider education, termination, legal action, overpayment recovery, etc.  If you know of or become aware of provider fraud, waste and abuse, please let us know using the contact information below.

You can report fraud, waste and abuse to CareSource by:

You may also report fraud directly to the Michigan Department of Community Health (MDCH) by:

  • Calling 1-866-428-0005
  • Writing:

    Medicaid Integrity Program Section
    Capitol Commons Center Building, 6th Floor
    P.O. Box 30479
    400 South Pine Street
    Lansing, MI 48909-7979

When you report fraud, waste, or abuse, please give us as many details as you can, including names and phone numbers.  You may remain anonymous, but if you do, we will not be able to call you back for more information.  Your report will be kept confidential to the extent permitted by law.

False claims act 

On February 8, 2006, President George W. Bush signed the Deficit Reduction Act of 2005 into law. The Deficit Reduction Act contains many provisions reforming Medicare and Medicaid that are designed to reduce program spending.  As an entity that offers Medicaid and Medicare coverage, CareSource is required to comply with certain provisions of the Deficit Reduction Act. One such provision requires us to provide you with information about the Federal False Claims Act, state False Claims Acts, and other state laws regarding Medicare and Medicaid Fraud. In addition, the law requires you and your contractors and agents to adopt our policy on fraud, waste and abuse when handling CareSource business.

The Federal False Claims Act

Using the False Claims Act (the Act), you can help reduce fraud against the federal government. The Act allows everyday people to bring "whistleblower" lawsuits on behalf of the government- known as "qui tam" suits- against groups or other individuals that are defrauding the government through programs, agencies, or contracts.

The False Claims Act applies when a company or person:

  • Knowingly presents a false or fraudulent claim for payment, 
  • Knowingly uses a false record or statement to get a claim paid, 
  • Conspires with others to get a false or fraudulent claim paid, 
  • Knowingly uses a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property.

"Knowingly" means acting with actual knowledge or with reckless disregard or deliberate indifference to the truth or falsity of information.

An example would be if a health care provider, such as a hospital or a physician knowingly "upcodes" or overbills; resulting in overpayment of the claim using Medicaid dollars.

The time period for a claim to be brought under the False Claims Act is the later of:

  • Within six years from the date of the illegal conduct; or 
  • Within three years after the date the Government knows or should have known about the illegal conduct, but in no event later than ten years after the illegal activity.

Michigan state law

Michigan enacted its own False Claims Act in 2005. Under the Michigan Act, the following constitute felonious acts:

  1. Knowingly making or causing to be made a false statement or false representation of a material fact in an application for Medicaid benefits;
  2. Knowingly making or causing to be made a false statement or false representation of a material fact for use in determining rights to a Medicaid benefit;
  3. Having knowledge of the occurrence of an event affecting his or her initial or continued right to receive a Medicaid benefit or the initial or continued right of any other person on whose behalf he or she has applied for or is receiving a benefit, concealing or failing to disclose that event with intent to obtain a benefit to which the person or any other person is not entitled or in an amount greater than that to which the person or any other person is entitled;
  4. Soliciting, offering, or receiving a kickback or bribe in connection with the furnishing of goods or services for which payment is or may be made in whole or in part pursuant to the Medicaid program, making or receiving the payment, or receiving a rebate of a fee or charge for referring an individual to another person for the furnishing of the goods and services;
  5. Knowingly and willfully making, or inducing or seeking to induce the making of, a false statement or false representation of a material fact with respect to the conditions or operation of an institution or facility in order that the institution or facility may qualify, upon initial certification or upon recertification, as a hospital, skilled nursing facility, intermediate care facility, or home health agency;
  6. Entering into an agreement, combination, or conspiracy to defraud the state by obtaining or aiding another to obtain the payment or allowance of a false claim; or
  7. Making or presenting or causing to be made or presented to an employee or officer of the state a claim under the Medicaid program, knowing the claim to be false.  M.C.L.  §400.601, et seq. A person who violates the Michigan Act is guilty of a felony, punishable by imprisonment for not more than four (4) years, or by a fine of not more than $50,000.00, or both.

CareSource policy

It is the policy of CareSource to detect and prevent any activity that may violate the federal False Claims Act or the state Medicaid fraud laws cited in this policy. If any employee, Provider, delegated entity, subcontractor or agent has knowledge or information that any such activity may have taken place, they should contact the Special Investigations Unit. Contact information for Special Investigations is shown below. Information may be reported anonymously  and are confidential to the extent permitted by law.

In addition, federal and state law and CareSource's policy to prohibit any retaliation or retribution against persons who report suspected violations of these laws to law enforcement officials or who file "whistleblower" lawsuits on behalf of the government. Anyone who believes that he or she has been subject to any such retribution or retaliation should also report this to the Special Investigations Unit.

CareSource Special Investigations Unit contact information

Anonymously

Fraud Hotline: 800-390-7102 and follow the appropriate menu options.

Written Report: Write a letter or use the Fraud Reporting Form

CareSource
Attn: Special Investigations Unit
P.O. Box 1940
Dayton, OH 45401-1940

Other means of contact to CareSource that are not anonymous:

Fraud E-Mail: fraud@caresource.com

Fraud Fax: 800-418-0248

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You may contact the Michigan Department of Community Health, Program Investigation Section using:

Fraud Hotline: 866-428-0005

Written Report:

Medicaid Integrity Program Section
Capitol Commons Center Building, 6th Floor
P.O. Box 30479
400 South Pine Street
Lansing, MI 48909-7979

When you report fraud, waste or abuse, please give us as many details as you can, including names and phone numbers.  You may remain anonymous, but if you do, we will not be able to call you back for more information.  Your report will be kept confidential to the extent permitted by law.