- 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
Benefit Integrity
Providers have an obligation, under law, to conform to the requirements of Medicare. A key to avoiding fraud and abuse is the integrity of the provider as an entity and of each individual that is involved in any of the processes that result in a service being billed to Medicare.
Integrity is defined in the Merriam-Webster’s Collegiate Dictionary as: “Firm adherence to a code of especially moral or artistic values; incorruptibility – an unimpaired condition; soundness – the quality or state of being complete or undivided, completeness. A synonym is honesty.”
When you hear the following, it may indicate that you are on ethical thin ice:
- What’s in it for me?
- No one will get hurt.
- We can hide it.
- Well, maybe just this once…
- No one will ever find out.
- Everyone does it.
- It sounds too good to be true.
- Just change the numbers.
- We didn’t have this conversation.
- It doesn’t matter how it gets done, as long as it gets done.
It is every person’s ethical responsibility to report fraudulent activity. Health care fraud, whether against Medicare or private insurers, increases everyone’s health care costs, much the same as shoplifting increases the costs of food and clothing.
The Centers for Medicare & Medicaid Services (CMS) and its contractors have a responsibility in ensuring that the tax dollars used to pay for Medicare benefits are used appropriately. This is accomplished through efforts in prevention, detection, and recovery.
It is not assumed that all inappropriate payments are the result of fraudulent activity. Cases of suspected fraudulent activity are investigated. Subsequent prosecution of fraud is reserved for those instances when the fraudulent activity is substantiated and documented by repeated patterns of abuse. After the intermediary investigates, if abusive practices are found, and fraud is suspected, the case is referred to federal law enforcement agencies (i.e., the Office of the Inspector General [OIG], Federal Bureau of Investigation [FBI], or the United States Attorney’s Office) for prosecution. If a case of fraud is substantiated, substantial criminal fines/restitution, incarceration, and/or civil monetary penalties may be imposed when facts and circumstances warrant such action.
For those instances when fraud is not substantiated, there is a variety of remedies that may be used to further prevent or recover inappropriate payments:
- Education – Potentially inappropriate activities may be addressed through education via letters, personal contacts, group educational activities, and/or corrective action plans.
- Claim Review – Claims may be reviewed on a prepayment basis in order to identify and deny inappropriate payment before the claim is paid. Claims may also be reviewed on a prospective basis to identify and recover inappropriate payment of claims.
- Refunds – When Medicare or the provider identifies that an inappropriate payment was made, Medicare can request a refund with or without further punitive action.
- Suspension of Payment – In cases where fraud is suspected and it is determined that an entity has received payment inappropriately, the intermediary, through the authority of the CMS, may suspend a provider’s payments. That is, the intermediary will continue to accept and process the provider’s claims, but will withhold all payments.
Revised 1/2021