COMPLIANCE REPORTING

What is Corporate Compliance? 

Corporate Compliance is a management system aimed at detecting and preventing legal violations. It focuses on developing and maintaining internal controls to ensure compliance with federal, state, and local laws, while also promoting ethical behavior among employees. Compliance is important to prevent illegal activities from misappropriating Medicaid funds that should be used to protect the health and welfare of Medicaid beneficiaries. 

What is Fraud, Waste, and Abuse? 

• Fraud involves activities such as billing for services that were never provided, performing unnecessary treatments just to receive payment, altering documents to secure a higher payment, or submitting duplicate bills intentionally.  
• Waste refers to the excessive use of services that lead to unnecessary expenses. It can also mean spending resources without achieving a meaningful return. 
• Abuse includes submitting claims that do not adhere to billing guidelines, offering services that are not medically necessary or do not comply with accepted professional standards, or billing Medicare or Medicaid when a primary insurer is responsible for payment. 

What Needs to be Reported? 

• Inappropriate interactions between team members and persons served 
• Inappropriate business interactions among team members 
• Improper documentation of services 
• Information that is unrelated to the Individual Plan of Service (IPOS) or duplicated documentation 
• Billing for services that were not provided 
• Any situation where a team member seems to be exploiting an individual served for personal gain 
• Violations of confidentiality laws, including HIPAA, the Michigan Mental Health Code, or 42 CFR Part 2 (related to substance use) 
• Any actions that appear irregular, suspiciously inaccurate, or inconsistent with the organization’s standards 

It’s important to be aware of these issues to maintain a safe and professional environment.