Fraud and Abuse

Millions of health care dollars are wasted every year because of fraud and abuse. Priority Health takes these issues seriously. We need your help.

Fraud
Fraud is when someone lies or doesn't tell the truth in order to get a benefit. They do this because they might not be able to get the benefit if they told the truth.

Examples of fraud by members are:

• Loaning your ID card to someone else
• Changing or forging a prescription
• Telling a lie to get medial or pharmacy services

Examples of fraud by doctors are:

• Billing for services that were not done
• Billing a member for more than their copayment
• Changing the bill to get a denied claim paid

Abuse
Abuse is when you do something that leads to extra costs for Priority Health or the Medicaid Program.

Examples of abuse by members are:

• Going to the emergency room for non-emergency medical services
• Using transportation services for something other than what it is approved
• Bad or rude behavior in a doctor's office, hospital or pharmacy

Example of abuse by doctors:

• Prescribing drugs that are not medically necessary

Reporting Fraud and Abuse
If you suspect someone of fraud or abuse, please contact Priority Health right away. You do not have to give your name, address or phone number.

• Call customer service at 616 942-1221 or 800 446-5674
• Call the Compliance helpline at 800 560-7013 (available 24 hours a day)
• Write to:
  Priority Health Fraud and Abuse Program
  Finance Department - Mail Stop 2305
  1231 East Beltline NE
  Grand Rapids, MI 49525-4501
  
  You can also contact the State of Michigan Medicaid department directly about fraud or abuse. You do not have to give your name, address or phone number.
  • Call toll-free 866 428-0005
  • On the Internet, go to www.michigan.gov/mdch. Click on
    1. "Inside Community Health"
    2. "Fraud and Abuse"
    3. "Fraud and Abuse Reporting Requirements"
    4. "Medicaid Fraud/Abuse Online Complaint Form" located at the top right of the screen. Follow the instructions provided.
  • Write to:
    Program Investigation Section
    Capitol Commons Center Building
    400 South Pine, 6th Floor
    Lansing, Michigan 48909