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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:
Last modified
10/10/07
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