What is Fraud?
What is not Fraud?
Definition
Examples
What is Fraud?
Making false statements or misrepresentations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.
What is not Fraud?
· Complaints or inquiries regarding coverage policy
· Complaints alleging assignment violations
· Excessive charges
· Complaints over the status of a claim
· Requests for reconsideration or appeal
Complaints that may or may not be considered fraud:
· Billing errors and/or improper billing
· Questions of medical necessity
· Who should pay first
· Quality of care
Definition
Fraud is the intentional deception or misrepresentation that an individual
knows to be false, or does not believe to be true and makes, knowing that the
deception could result in some unauthorized benefit to them or some other person.
Examples
Typically, Medicare fraud fits into one of these categories:
· Billing for services not furnished
· Billing for a higher dollar service than what was provided (upcoding)
· Claiming services or items which were not authorized by a physician
· Falsely indicating that a service was medically necessary
· Misrepresenting a diagnosis in order to get a higher payment rate
· Kickback schemes
· Unbundling (charging separately for items that should be billed together
as a package or bundle)
· Falsifying records such as certificates of medical necessity, plans
of treatment, or medical records
· Creating fictitious payrolls