Fraud means an intentional deception, misrepresentation, false statement(s) or false representation of material facts with the knowledge that the deception could result in unauthorized benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the personís own benefit or for the benefit of some other party. It includes any act that constitutes fraud under applicable Federal or State law.
Abuse means practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to Grand Valley Health Plan or in reimbursement for services that are not medically necessary, violation of an agreement or certificate of coverage, or that fail to meet professionally recognized standards for health care. It includes member, employer group, agent or provider practices that result in unnecessary cost to Grand Valley Health Plan.
The following are examples of Fraud and Abuse:
a member shares his/her GVHP Health Membership ID card
a member does not take a dependent off their policy when the dependent is no longer eligible for coverage (example: a child turns 18 and is no longer a full-time student)
a member and/or health care provider overstates the member's illness
a member forges a prescription or obtains medication to resell it
a health care provider bills for services not provided
a health care provider charges Grand Valley Health Plan twice for the same service
a health care provider receives payments for making patient referrals
an employer group lists non-employees on their payroll to receive health care benefits from Grand Valley Health Plan
If you have any questions about our fraud and abuse statement, you may send an e-mail to: firstname.lastname@example.org or contact Grand Valley Health Plan by phone at 866-203-7456.