Deciphering Healthcare Fraud and Abuse Laws

 Deciphering Healthcare Fraud and Abuse Laws


In 2014, Feds recovered 3.3 billion in healthcare fraud, which is about a billion less than what they recovered in 2013. In case of medical billing and coding, a single mistake  could put your provider at risk for investigation and audit for healthcare fraud and abuse. To avoid being the recipient of investigation, it is critical to understand the fundamentals of fraud and abuse. It is a crime to defraud the Federal Government and its programs, and the punishments in case of violation ranges from imprisonment, penalties, fines, and even cancellation of license of providers and health care organizations. Additionally, fraud and abuse can also expose you and your organization to civil and criminal liability.

Fraud and Abuse: What’s the Difference

According to the Centers for Medicare & Medicaid Services (CMS):

Medicare Fraud refers to making false statements or misrepresenting facts to obtain a benefit or payment that would not otherwise exist. A person’s may commit fraud for its own benefit or for the benefit of some other party. This offence covers individual to vast operations by an institution or group. According to CMS anyone can commit health care fraud. And if you know someone who has committed fraud, you can always report it and be a whistleblower.

Examples of Medicare fraud – Billing for services and/or supplies that you know were not furnished or provided; and Altering claims forms and/or receipts to receive a higher payment amount.

Medicare Abuse refers to any action that, either directly or indirectly, results in unnecessary costs to the Medicare Program. It covers any practice that does not provide Medicare beneficiaries with services that are medically necessary, fairly priced, and meet professionally-recognized standards.

Examples of Medicare abuse:

  • Misusing codes on a claim;
  • Charging excessively for services or supplies; and



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