Definitions of fraud and abuse

Definitions are a little different depending on which plan you have.

Jump to:

• Priority Health plan definitions, including PriorityMedicare
• Medicaid plan definitions
• MIChild plan definitions

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Definitions used by most Priority Health plans, including PriorityMedicare

Fraud:
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:
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 the Priority Health.

Waste:
Waste is generally defined as activities that unjustly enrich a person through the receipt of benefit payments but where the intent to deceive is not present; or is an attempt by an individual to obtain a benefit payment he or she does not deserve.

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Definitions used by the Medicaid plan

Fraud:
Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable Federal or State law (42 CFR § 455.2)

Abuse:
Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes recipient practices that result in unnecessary cost to the Medicaid program.  (42 CFR § 455.2)

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Definitions used by the MIChild health plan

Fraud:
Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable Federal or State law (42 CFR § 455.2)

Abuse:
Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the MIChild program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes beneficiary practices that result in unnecessary cost to the MIChild program.