Audits and investigations of fraud, waste and abuse
The Priority Health Fraud, Waste and Abuse (FWA) program is administered by our Special Investigations Unit 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.
Providers selected for audit are notified directly by the Priority Health Special Investigations Unit or by one of our vendor partners. Our vendor partners identify themselves and indicate they are performing the audit on behalf of Priority Health.
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.
- NPI numbers
- Electronic funds transfer (EFT)
- Physician status
- Open or close to new patients
- Availability standards
- Changes to address or staff
- Provider-patient relationship
- Medical & office records
- Medicaid patient treatment
- Medicare patient treatment
- Site visits
- Fraud, waste & abuse
- Utilization Management Program