Priority Health - Scam Alert: Fraudulent Prescription and Certificates of Medical Necessity (CMN) Requests

Priority Health has identified a large-scale scam in the market affecting commercial and Medicare members, including Priority Health members. The scam has also impacted other insurance carriers and providers in and outside of Michigan.

What you need to know

Be on alert for any prescriptions or certificates of medical necessity (CMN) received through fax from pharmacies or suppliers, indicating the patient has requested the medication or supplies.

 

Examples of fraudulent requests:

• Over-the-counter vitamins and ointments

• Compound creams

• Topical pain creams (lidocaine, diclofenac sodium, Vanatol LQ, and combination packs)

• Scar and skin creams (Urevaz or fluocinonide)

• Non-steroidal anti-inflammatory drugs such as mefenamic acid or fenoprofen calcium

• Braces – knee, neck, back, or wrist

• Diabetic supplies, blood glucose meters, alcohol pads, test strips, lancet devices, control solutions, and lancets

• TENS units and associated supplies, such as electrodes, leads, and batteries

 

How to identify these fraudulent prescriptions:

• The prescription or CMN typically will be completed with the medication or supplies and SIG (label or directions) already filled in, including the number of refills.

• The quantity of the medication will be high. Most ointments, gels, and creams are dispensed in grams. Most tubes and jars come in sizes of 35.4-, 50-, or 100-gram sizes. The questionable prescriptions could list the quantity anywhere from 248 to 744 grams

. • The prescription could list multiple options in categories such as topical pain therapy, wellness, scar or dermatitis, eczema, general or diabetic neuropath, inflammatory pain, arthritis, acid reflux or GERD.

• The pharmacy differs from the members normal pharmacy

The list of medications can change.

 

What providers need to do

Please review any prescription carefully that your office did not initiate. If the medication is not medically necessary for the patient, please do not approve the request.

If you believe your office has received questionable prescriptions for Priority Health members, contact our Provider Helpline at 800.942.4765 or download and complete our Fraud, Waste and Abuse Complaint Form and submit to Priority Health via email or fax with the information provided on the form.