As the health care industry becomes more complex, so does compliance regarding the False Claims Act, Medicare Fraud, Medicare Abuse, Anti-Kickback Statute (AKS), Stark Law, and Criminal Health Care Fraud Statute.
Below is a brief summary as to how medicare abuse may be defined and or interpreted.
Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse may include any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.
The difference between “fraud” and “abuse” may depend on specific facts, circumstances, intent, and knowledge.
Examples of Medicare abuse may include:
- Billing for unnecessary medical services;
- Charging excessively for services or supplies; and/or
- Misusing codes on a claim, such as upcoding or unbundling codes. Upcoding is when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement.
Medicare abuse can also expose providers to criminal and civil liability.
Program integrity includes a range of activities targeting various causes of improper payments. Possible types of improper payments:
- Mistakes - Results in errors: such as incorrect coding;
- Inefficiencies - Result in waste: such as ordering excessive diagnostics tests;
- Bending the rules - Results in abuse: such as improper billing practices (like up-coding); and/or
- Intentional deceptions - Result in fraud: such as billing for services or supplies that were not provided.
Courtesy of CMS (2/19)
