Fraud and Abuse

Help Stop Fraud and Abuse

Fraud occurs when people intentionally misstate facts to secure some benefit for themselves or others. Wasteful practices or things that cost the health plan more money than they should are considered abuse.

Healthcare fraud is a crime that has a significant effect on the private and public healthcare payment system. Fraud and abuse account for more than 10 percent of annual healthcare costs. Taxpayers pay higher taxes because of fraud in public programs such as Medicaid and Medicare. Employers and individuals pay higher private health insurance premiums because of fraud in the private sector healthcare system.
Recognizing the serious implications of fraud, Physicians Health Plan (PHP) is dedicated to detecting, investigating and preventing all forms of suspicious activities related to possible healthcare fraud and abuse, including any reasonable belief that insurance fraud will be, is being or has been committed.

PHP has a program to help stop fraud and abuse.  Fraud or abuse can be committed by many different parties, including providers, members and PHP employees. 

Examples of Member Fraud and Abuse Include:

  • Using an expired PHP ID card
  • Letting a friend of family member use a PHP ID card
  • Changing a prescription
  • Trying to get a refill that is not allowed on a prescription
  • Selling prescribed drugs or other medical equipment paid for by PHP
  • Telling a lie to get medical services
  • Going to the emergency room for nonemergency medical care
  • Threatening others or behaving abusively in a provider’s office, hospital, or pharmacy

Examples of Provider Fraud and Abuse Include:

  • Billing for services that were not performed
  • Upcoding or double billing
  • Improper utilization (either billing for services that were not medically necessary or not ordering services that are medically necessary)
  • Lying about a diagnosis in order to ensure health coverage for the patient
  • Prescribing drugs, equipment, or services that are not necessary

Examples of Employee Fraud and Abuse Include:

  • Intentionally submitting false claims
  • Self-dealing (referring members only to providers with whom the employee has a financial relationship)
  • Intentionally denying benefits
  • Embezzlement or theft

Examples of Group Eligibility Fraud and Abuse Include:

  • Adding an ineligible individual as a dependent (e.g., listing someone as a “spouse” when not married to that individual)
  • Allowing someone who is not employed with, or who does not meet the eligibility requirements for, your company to enroll or remain enrolled as if the person were an employee or met eligibility requirements
  • Failing to notify PHP or the plan administrator of a divorce and continuing to cover an ex-spouse
  • Misrepresenting the date of birth of a dependent in order to meet age-related eligibility requirements
Please call the PHP Compliance Hotline at 517.267.9990 if you detect fraud or abuse. Calls can remain anonymous and confidential.

You also can send a letter to:

Attn: Compliance Department
Physicians Health Plan
PO Box 30377
Lansing, MI 48909-7877
Suspicions or knowledge about fraud, waste and abuse regarding Medicaid services can be shared directly with the State of Michigan Office of Inspector General by calling 1.855.MI.FRAUD (643.7283), going online at or by sending a letter to:
Office of Inspector General
PO Box 30479
Lansing, MI 48909
Reporting to the Office of Inspector General can be done anonymously.