Audits and investigations of fraud, waste and abuse

The Priority Health Fraud, Waste and Abuse (FWA) program is administered by our Special Investigations Unit and Payment Integrity team with the help of our vendor partners. In addition to reducing fraud, waste and abuse, we want to be sure we're protecting our customers and meeting compliance and regulatory requirements.

Documentation and coding errors may not be intentional but can have significant impact on the member and health plan. It is important to identify and make corrections when errors are found.

How providers are identified for audit

Priority Health both follows up on tips and referrals and performs claims data mining to identify suspicious claims that require further investigation.

Suspicious claims are audited for validation.

Audit notifications

Providers selected for audit are notified directly by the Priority Health Special Investigations Unit, Payment Integrity or by one of our vendor partners. Our vendor partners identify themselves and indicate they are performing the audit on behalf of Priority Health.

Documentation requirements

Claims must include relevant documentation (i.e., medical records) to be reimbursed. Failure to submit requested documentation may result in an audit and claim denial.

Disputing audit results

Audited providers who disagree with some or all of the audit findings may dispute the findings. Instructions for submitting a dispute are included in the audit findings letter. See the processes below for details.