Question

Distinguish between healthcare fraud and abuse. Provide an example of each.

Answer 1

Ans) Healthcare fraud & Abuse:

Fraud is defined as any deliberate and dishonest act committed with the knowledge that it could result in an unauthorized benefit to the person committing the act or someone else who is similarly not entitled to the benefit. Examples of healthcare fraud are:

• Misrepresentation of the type or level of service provided;
• Misrepresentation of the individual rendering service;
• Billing for items and services that have not been rendered;
• Billing for services that have not been properly documented;
• Billing for items and services that are not medically necessary;
• Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);
• Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding).

Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

Examples of healthcare Abuse are:

• Misusing codes on a claim;
• Charging excessively for services or supplies; and
• Billing for services that were not medically necessary.

Both fraud and abuse can expose a provider or vendor to criminal and civil liability.