Benefit Integrity - Healthcare Fraud and Abuse

Frequently Asked Questions

What is the difference between fraud and abuse?

Fraud is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in unauthorized payment. Keep in mind the attempt itself is fraud, regardless of whether it is successful.

Abuse involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments.

The real difference between fraud and abuse is the person's intent. Both activities have the same impact: they detract valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.

What can I do if I suspect Medicare fraud?

• Beneficiary Instructions - Information to contact the Office of Inspector General (OIG) hotline and their Affiliated Contractor (AC) (via telephone, US mail, and e-mail)

Do healthcare providers in the Medicare program perpetrate fraud and abuse?

Most physicians, suppliers, and other healthcare workers providing services to Medicare members are honest. However, some willfully enter the Medicare program to perpetrate fraud, and some intentionally and consistently defraud Medicare by padding their bills.

For more information visit www.nhcaa.org or www.cfenet.com or www.fraudweek.com.

What are some examples of Medicare fraud?

Medicare fraud is usually comprised of false statements or misrepresentations made in order to receive payment under the Medicare program. The following are some examples of Medicare fraud cited on the CMS Webpage "Medicare Definition of Fraud":

• Billing for services not furnished
• Misrepresenting the diagnosis to justify payment
• Unbundling or "exploding" charges
• Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment
• Billing for a service not furnished as billed (up-coding)
• Providing information to a Medicare contractor that the provider knows to be false or incorrect
• Placing nonallowable expenses on the Medicare Cost Report