Fraud

We continuously monitor claims trends and variant billing to detect fraudulent activity. Fraud is a criminal offence and we follow up all cases with referral to regulating organisations or the Police as appropriate.

We consider all the following to be fraud

  • Up-coding - billing a procedure of higher complexity than the one that was performed
  • Unbundling - additionally billing for component parts of a complex procedure
  • Billing for services that were not provided
  • Billing for services that were not medically necessary
  • Altering dates, description of services or medical records to secure payment
  • Misrepresentation of diagnoses or procedures to maximise payment


To avoid any doubt, read our unbundling rules.

PruHealth fully supports and has been active in the development of the CCSD Coding Principles which define unacceptable code combinations. These can be found on the CCSD website.

PruHealth is an active member of the Health Insurer Counter Fraud Group and shares information with other insurers for the detection and prevention of of fraud subject to the provisions of the Data Protection Act.

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