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Provider Manual - Fraud and Abuse
Healthcare Fraud is an intentional deception or misrepresentation that the individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual, entity, or to some other party.
It is speculated that between 10% and 20% of the dollars paid by insurance companies could be attributable to Healthcare Fraud and Abuse. False claims can be divided into two categories: fraudulent and abusive.
Public Employees Health Program has established a Special Investigative Unit comprised of a Special Investigator, Provider Relations Representative, Claims Review Representative, Finance/Healthcare Analysis Representative, Claims Representative and a Case Management Representative. The SIU duties include desk and on site audits, providing internal and external fraud and abuse training, and preparation of information for criminal investigations. Investigations include providers with aberrant billing practices to determine if the practice constitutes over-utilization or fraud and includes member eligibility fraud and prescription abuse.
When the SIU staff discovers a pattern of fraudulent, abusive, or inappropriate billing practices, they will take appropriate measures to stop the activity. Claims may be denied and refunds requested for previously processed claims. Cases may be referred to the Utah Insurance Fraud Division for investigation and possible prosecution.
Please report suspected fraudulent activity to PEHP by calling 801-366-7529. You may remain anonymous.
Examples of fraudlent, abusive, or inappropriate billing for services
- Filing claims for services not provided.
- A pattern of billing that includes submitting incorrect or misleading diagnostic or procedure codes, which leads to incorrect processing services.
- Billing for more expensive service than was actually performed (upcoding).
- Advertising free or discounted services, then billing PEHP for additional services that may or may not be medially necessary.
- Billing for services or treatment performed on a family member, even those with different last names.
- Submitting claims for charges that, in the absence of the member’s insurance, there would be no obligation to pay; services provided by a family member (It is inappropriate to bill for services that, in the absence of insurance coverage, would become “professional courtesy,” i.e., for members of your staff and members of your group practice and their families.).
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