FAQs

Billing for services not rendered is one of the most common types of fraud committed by providers. However, there are instances when a provider mistakenly submits a claim with an incorrect identification number, causing payment to be issued under the wrong patient. Always report erroneous charges; PEHP will thoroughly research the charges and determine whether it is fraud or simply a billing error.

Once your divorce is final, coverage terminates at midnight on the day prior to your divorce date. The divorced spouse is no longer a dependent and if he/she continues using your benefits, you are responsible for any payments made erroneously. Dependent children for whom the Subscriber is required to provide medical insurance as ordered in a divorce decree may continue Coverage. Stepchildren who no longer have a Parental Relationship with a Subscriber will no longer be eligible to receive benefits under PEHP.

No, this is considered billing for services not provided and should be reported to PEHP immediately.

Never be afraid to report a doctor for suspicion of fraudulent billing or inappropriate behavior. You’re not required to identify yourself when reporting fraud. PEHP takes every complaint seriously and is committed to protecting your confidentiality. Remember, if the provider is filing fraudulent charges regarding you, then he/she may be filing wrongful charges with others as well.

• Billing for services not provided
• Double billing
• Billing for services performed by non-licensed or ineligible providers
• "Unbundling" or billing separately for component parts of a medical procedure
• "Up coding" or billing for a higher level of service than was performed
• Billing for services originally advertised as "free"
• Overutilization of services
• Billing non-covered services as covered services
• Billing under another family member when maximum benefits have been paid on the actual patient
• Prescribing, then offering to buy back, powerful narcotics after the insurance has paid for the prescription