Here are some examples to help you know what is considered fraud and abuse. Provider Examples of potential provider fraud and abuse include: Submitting bills or claims for treatment or services that were never provided Claiming a false date of service to correspond with a member’s coverage period Billing for non-covered services using incorrect codes to attempt to have services covered Pharmacy Examples of potential pharmacy fraud and abuse include: Incorrect pharmacy billing Bills for medication that was never dispensed Bills for brand name drugs, but dispensed generic drugs Prescription drug shorting Less than the prescribed quantity is intentionally provided and the patient is not informed Prescription forging or altering – done without the prescriber’s permission to increase the quantity of tablets or number of refills Member or patient Examples of potential member or patient fraud and abuse include: Submitting false claims Prescription stockpiling and unlawful sales of excessive services and goods for resale Concealing information about additional coverage in order to lower out-of-pocket payments, or receiving inappropriate reimbursement from multiple plans Identity theft Doctor shopping Multiple providers are seen in an attempt to obtain multiple prescriptions. Usually includes deception and can be driven by addiction, drug diversion for profit or both.