FRAUD AND ABUSE

What Is Fraud?

Fraud is defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.

Examples of Fraud
• Billing for services not rendered.
• Soliciting, offering, or receiving a kickback, bribe, or rebate.
• Using an incorrect or inappropriate provider number in order to be paid (e.g., using a deceased Provider’s number).
• Signing blank records or certification forms that are used by another entity to obtain payment.
• Selling or sharing patients’ identification numbers so false claims can be filed.
• Offering incentives to Medicare patients that are not offered to non-Medicare patients (e.g., routinely waiving or discounting the Medicare deductible and/or coinsurance amounts).
• Falsifying information on applications, medical records, billing statements, and/or cost reports.
• Misrepresenting as medically necessary, non-covered services by using inappropriate procedure or diagnosis codes.

What Is Abuse?

Abuse may, directly or indirectly, result in unnecessary costs to the insurer, improper payment, or payment for services which fail to meet professionally recognized standards of care, or that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Although many types of inappropriate practices may initially be considered abusive, they may evolve into fraud.

Examples of Abuse
• Using procedure or revenue codes that describe more extensive services than those actually performed.
• Unbundling charges.
• Collecting more than the coinsurance or the deductible.
• Routinely submitting duplicate claims.
• Billing for services grossly in excess of those needed by patients. For example, always billing for complete lab profiles when only a single diagnostic test is necessary to establish diagnosis.