Fraud & abuse examples

Examples of medical identity theft

• Someone takes your Priority Health ID card to get services from a doctor or hospital, or to get prescription drugs from a pharmacy.
• You lend someone your Priority Health ID card and they use it to get services or prescription drugs.
• A doctor or hospital uses your Priority Health ID number and your health care information to bill Priority Health for services you didn't get.

Examples of fraud by members

• Sharing a Priority Health, Medicaid, MIChild, or Medicare ID card with someone else so they can use your health benefits
• Providing false information when applying for health care coverage
• Providing false information to a doctor or other health care provider
• Not taking a child off a policy when the child is no longer a dependent (example: a child turns 18 and is no longer a full-time student)
• Keeping a husband or wife on a policy after a divorce is final
• Changing or forging a prescription
• Calling in prescriptions by pretending to be a doctor
• Selling your prescription drugs

Examples of fraud by health care providers

• Charging Priority Health for services that were not provided to a Priority Health member
• Charging twice for the same service
• Getting "kickback" payments from hospitals or specialists for referring patients to them
• Misrepresenting what services were provided the patient, or the patient's condition or diagnosis, or the identity of the health care provider or patient
• Billing for a service that is covered instead of the actual service provided, when the actual service is not covered by Priority Health 
• Changing a patient's medical record (dates of service, reporting visits when the patient was not actually seen, deleting information) to get a claim paid
• Routinely not collecting a patient's copay when it should have been collected
• Billing a patient for services that Priority Health has already paid for

Examples of fraud by employers

• Listing non-employees on their payroll so they can get health benefits from Priority Health
• Not telling Priority Health when an employee has resigned or been fired and needs to be removed from the plan
• Not telling Priority Health that their business has closed so they can keep the group health insurance

Examples of fraud by pharmacies

• Filling only part of your prescription for a drug without telling you it's "short" and explaining how and when you can get the rest of the prescription at no extra charge
• Splitting your prescription into two orders to bill Priority Health twice

Learn more

Legal definitions of fraud and abuse
How to protect yourself from medical identity theft
How to report fraud and/or abuse to Priority Health