Question

Define and differentiate Medicare fraud and abuse and describe at least three related acts. Reply

Answer 1

Medicare fraud typically includes any of the following:

● Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist.

● Knowingly soliciting, receiving, offering, or paying remuneration (e.g., kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by Federal health care programs

● Making prohibited referrals for certain designated health services.

Anyone can commit health care fraud. Fraud schemes range from solo ventures to widespread activities by an institution or group. Even organized crime groups infiltrate the Medicare Program and operate as Medicare providers and suppliers. Examples of Medicare fraud include:

● Knowingly billing for services at a level of complexity higher than services actually provided or documented in the medical records
● Knowingly billing for services not furnished, supplies not provided, or both, including falsifying records to show delivery of such items
● Paying for referrals of Federal health care program beneficiaries
● Billing Medicare for appointments patients fail to keep.

Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

The difference between “fraud” and “abuse” depends on specific facts, circumstances, intent, and knowledge. Examples of Medicare abuse include:

● Billing for unnecessary medical services
● Charging excessively for services or supplies
● 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.

Federal laws governing Medicare fraud and abuse include the:

● False Claims Act (FCA)
● Anti-Kickback Statute (AKS)
● Physician Self-Referral Law (Stark Law)
● Social Security Act, which includes the Exclusion Statute and the Civil Monetary Penalties Law (CMPL)
● United States Criminal Code