Fraud & abuse examples
Examples of medical identity theft
- Someone takes your Priority Health membership card to get services from a doctor or hospital, or to get prescription drugs from a pharmacy.
- You lend someone your Priority Health membership card and they use it to get services or prescription drugs.
- A doctor or hospital uses your Priority Health membership number and your health care information to bill Priority Health for services you didn't get.
It's important to check the Explanation of Benefits (EOB) forms we send you to make sure there are no services listed that you didn't receive. Call us right away if you see any mysterious charges.
Examples of fraud by members
- Sharing a Priority Health, Medicaid or Medicare 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
- 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
- Going to the ER, urgent care center or a doctor to get pain medications when there's no medical need for them
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 or for ordering unnecessary tests
- Misrepresenting the services provided, the patient's condition or the identity of the health care provider who performed the service
- 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