Fraud, Waste & Abuse in Health Care
Definitions
Definitions
Terms have legal significance
Fraud
Definitions
Fraud
Definitions
Action: Knowingly making a false statement or claim
Fraud
Definitions
Action: Knowingly making a false statement or claim
Result: Funding unauthorized benefit
Fraud
Definitions
Example: Filing a claim on services that were never performed
Waste
Definitions
Waste
Definitions
Action: Misuse or overuse of resources
Waste
Definitions
Action: Misuse or overuse of resources
Result: Funding unnecessary costs
Waste
Definitions
Example: Writing high-cost prescriptions over less
expensive generic prescriptions
Abuse
Definitions
Abuse
Definitions
Action: Improper use of info or documentation
Abuse
Definitions
Action: Improper use of infoor documentation
Result: Funding for personal gain without evidence of
criminal intent
Abuse
Definitions
Example: 99215 E/M for one hour when the visit was actually only 15 minutes
How prevalent is fraud & abuse inU.S. health care?
In 2011, $98 billion was lost due to
Medicare/Medicaid fraud & abuse
What is the government doing
to prevent fraud & abuse?
1965
Title XIX to SSA
1965 1977
Anti-Fraud & Abuse Amendments
Title XIX to SSA
1965 1977
Anti-Fraud & Abuse Amendments
Title XIX to SSA
1986
False Claims Act
1965 1977
Anti-Fraud & Abuse Amendments
Title XIX to SSA
1986
False Claims Act
1996
HIPAA
1965 1977
Anti-Fraud & Abuse Amendments
Title XIX to SSA
1986
False Claims Act
1996 2005
Deficit Reduction Act
HIPAA
1965 1977
Anti-Fraud & Abuse Amendments
Title XIX to SSA
1986
False Claims Act
1996
HIPAA
2005
Deficit Reduction Act
2009
Healthcare Fraud Prevention & Enforcement
Action Team (HEAT)
2009
American Recovery &
Reinvestment Act/ HITECH
Meaningful Use
2009
American Recovery &
Reinvestment Act/ HITECH
Meaningful Use
2010
Affordable Care Act
2009
American Recovery &
Reinvestment Act/ HITECH
Meaningful Use
2010
Affordable Care Act
Center for Program Integrity
2009
American Recovery &
Reinvestment Act/ HITECH
Meaningful Use
2010
Affordable Care Act
Center for Program Integrity
2012
OIG Releases Report on E/Ms
& EHRs
Healthcare Reform
Want to learn more about fraud & abuse in health care?
Visit successehs.com/archived-webinars to view the free, complete webinar + slides, “EHRs, RAC Audits & Coding –
What Providers Need to Know”
