- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 3: Fraud and Abuse
Fraud and Abuse
Table of Contents
Fraud and Abuse
Fraud occurs when there is an intentional deception or misrepresentation that an individual knows to be false or does not believe to be true, and the individual knows that the deception could result in some unauthorized benefit to himself/herself or some other person.
Abuse consists of billing Medicare for services that are not covered or are not correctly coded.
Preventing and detecting potential fraud involves a cooperative effort among the following:
- Beneficiaries
- MACs
- Providers
- QIOs
- State Medicaid Fraud Control Units (MFCU)
- CMS
- OIG
- OCIG
- DHHS
- FBI
- DOJ
The person or entity involved in a fraud or abuse activity may be a provider, a beneficiary, an employee of a provider, or some other person or business entity, including a billing service, or an intermediary employee.
Examples of Fraud
Fraud may take such forms as:
- Incorrect reporting of diagnoses or procedures to maximize payments.
- Billing for services not furnished and/or supplies not provided. This includes billing Medicare for appointments that the patient failed to keep.
- Deliberate billing for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service, or billing both Medicare and another insurer in an attempt to be paid twice.
- Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount.
- Soliciting, offering, or receiving a kickback, bribe, or rebate, e.g., paying for a referral of patients in exchange for the ordering of diagnostic tests and other services or medical equipment.
- Unbundling charges.
- Participating in schemes that involve collusion between a provider and a beneficiary, or between a supplier and a provider, and result in higher costs or charges to the Medicare Program.
- Participating in schemes that involve collusion between a provider and a contractor employee where the claim is assigned, e.g., the provider deliberately overbills for services, and the contractor employee then generates adjustments with little or no awareness on the part of the beneficiary.
- Billing based on gang visits, e.g., a physician visits a nursing home and bills for 20 nursing home visits without furnishing any specific service to individual patients.
- Misrepresentations of dates and descriptions of services furnished or the identity of the beneficiary or the individual who furnished the services.
- Billing noncovered or non-chargeable services as covered items.
- Repeatedly violating the participation agreement.
- Using another person’s Medicare card to obtain medical care.
- Giving false information about provider ownership in a clinical laboratory.
- Using the adjustment payment process to generate fraudulent payments.
Examples of cost report fraud may include:
- Incorrectly apportioning costs on cost reports.
- Including costs of noncovered services, supplies, or equipment in allowable costs.
- Arrangements by providers with employees, independent contractors, suppliers, and others that appear to be designed primarily to overcharge the Program through various devices (commissions, fee splitting) to siphon off or conceal illegal profits.
- Billing Medicare for costs not incurred or which were attributable to nonprogram activities, other enterprises, or personal expenses.
- Repeatedly including unallowable cost items on a provider’s cost report except for purposes of establishing a basis for appeal.
- Manipulation of statistics to obtain additional payment, such as increasing the square footage in the outpatient areas to maximize payment.
- Claiming bad debts without first genuinely attempting to collect payment.
- Certain hospital-based physician arrangements and amounts also improperly paid to physicians.
- Amounts paid to owners or administrators that have been determined to be excessive in prior cost report settlements.
- Days that have been improperly reported and would result in an overpayment if not adjusted.
- Depreciation for assets that have been fully depreciated or sold.
- Depreciation methods not approved by Medicare.
- Interest expense for loans that have been repaid for an offset of interest income against the interest expense.
- Program data where provider program amounts cannot be supported.
- Improper allocation of costs to related organizations that have been determined to be improper.
- Accounting manipulations.
Examples of Abuse
Examples of abuse may include:
- Over utilization of medical and health care services.
- Improper billing practices (billing Medicare instead of primary insurer).
- Increasing charges to Medicare beneficiaries but not to other patients.
- Shifting costs to prospective payment system (PPS) exempt units.
- Unbundling of services.
- Routine waiver of deductible and coinsurance.
- Excessive compensation to employees.
- Not making adjustments to accounting and/or cost reports.
- Unnecessary transfers of patients between acute and PPS exempt unit.
Some of these abusive practices could also be considered fraud when the problem becomes a pattern, occurs after education is provided, or is intentionally done to receive unauthorized benefits.
Revised 1/2021