What are Fraud and Abuse?

As part of our efforts to keep the costs of health care down, Priority Health has a special team that detects and investigates potential fraud and abuse.

Read definitions and examples (below)
How to report fraud and abuse
Read frequently asked questions and answers


Definitions
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 person's 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 Priority Health 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 Priority Health.

View the Code of Federal Regulations (CFR): 42 CFR 455.2

Examples of fraud and abuse
You may have evidence of fraud or abuse if you suspect:

• A member shares his/her Priority Health ID card
• A member shares his/her Medicaid 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 Priority Health 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 Priority Health