What you should know about fraud, waste & abuse
Fraud, waste and abuse (FWA) drives up health care costs and can put your safety at risk. Priority Health is committed to the detection, prevention, investigation and correction of potential health care FWA and has established the Special Investigations Unit (SIU) to lead this effort. Taking on this challenge takes teamwork and the SIU looks to you as an important partner. Read on to learn more about FWA and how to report your concerns.
What is Fraud, Waste and Abuse?
- Fraud is a dishonest act. A person or company commits fraud knowing it is wrong and could result in their getting money, services or other benefits they have no right to.
- Waste is the over-utilization of services or other practices that directly or indirectly result in unnecessary cost to the healthcare system.
- Abuse is using, or providing, health care services that are probably not needed, which results in unnecessary costs to you or to your insurance company.
Read the complete legal definitions.
FWA takes on many forms which makes it hard to spot.
Here are some examples:
- Member alters or forges a prescription
- Member sharing his or her ID card with another person
- Someone else uses your insurance card to obtain health care services
- Member obtains unnecessary equipment and supplies
- Doctor bills for services not performed
- Doctor bills more than once for the same service
- Doctor not ordering services that are medically necessary
- Pharmacy bills for drugs or items that you have not received
Be proactive and protect yourself
- Protect your insurance identification card like you would protect your social security number, credit cards or checkbooks
- Don't give you card or number to a stranger who offers you free medical tests, products or services
- Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid
- Carefully review the Explanation of Benefits (EOBS) that you receive from us
- Review your claims history to make sure we have not been billed for services you did not receive
Report your concerns
You’re our best ally when it comes to preventing health care fraud, waste and abuse. If you spot any suspicious activities report your concerns.