What is Fraud, Waste, and Abuse?Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person.
Waste - Practices that, directly or indirectly, result in unnecessary costs such as overusing services. Waste is generally not caused by criminally negligent actions, but rather misuse of resources.
Abuse - Activities that are inconsistent with sound fiscal, business, or medical practices that result in unnecessary cost, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards. Abuse involves paying for items or services when there is no legal entitlement to that payment, and the person has not knowingly or intentionaly misprepresented facts to obtain payment.
Examples of Fraud, Waste, and Abuse:
- Unnecessary treatments
- Using someone else's insurance card
- Altering or forging a prescription
- Providing misleading information on or omitting information from an application for health care coverage
- Billing for services not rendered and/or goods not provided
- Knowingly enrolling someone not eligible for coverage under their policy or coverage
- Double billing
- Misrepresentation of services
- Billing separately for services that should be a single service
- Billing for services not medically necessary
- False coding, altering records, or claims
- Altering medical record documentation
- Limiting access to needed services
- Soliciting, offering, or receiving a kickback, bribe, or rebate
- Misrepresentation of medical conditions
