Definitions of fraud and abuse
Definitions are a little different depending on which plan you have.
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Definitions used by most Priority Health plans, including Priority Health Medicare
Fraud: Fraud means an intentional deception, misrepresentation, false statement(s) or false representation of material facts with the knowledge that the deception could result in unauthorized benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person's own benefit or for the benefit of some other party. It includes any act that constitutes fraud under applicable Federal or State law.
Abuse:
Abuse means practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to Priority Health or in reimbursement for services that are not medically necessary, violation of an agreement or certificate of coverage, or that fail to meet professionally recognized standards for health care. It includes member, employer group, agent or provider practices that result in unnecessary cost to the Priority Health.
Waste:
Waste refers to the extra costs that happen when health care services are overused or when bills for services are prepared incorrectly. Unlike fraud, waste is usually caused by mistake rather than illegal or intentionally wrongful actions.
Definitions used by the Medicaid plan
Fraud:
Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR § 455.2)
Abuse:
Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (42 CFR § 455.2)
Definitions used by the MIChild health plan
Fraud:
Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR § 455.2)
Abuse:
Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the MIChild program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the MIChild program.
