What is considered healthcare fraud, waste, and/or abuse?
Fraud is knowingly and willfully executing, or attempting to execute, a scheme to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. In other words, fraud is intentionally submitting false information to the Government or a Government contractor to get money or a benefit. Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines of up to $250,000.
Waste includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Fraud, waste and abuse can include (but is not limited to):
- Billing for services that were never provided.
- False cost reports-expenses not related to services provided are included.
- Illegal kickbacks where providers may conspire with another provider to share monetary reimbursement received in exchange for service referrals. (This could include cash, vacation trips, automobiles or other items of value.)
- Improper payments for Medicaid services, which can include:
*Payment for services when service provision is not adequately documented
*Medically unnecessary services due to a lack of documentation in medical record to support eligibility and need for service
*Incorrect coding when billing for services, using the wrong code for a particular service
*Non-covered costs or services that do not meet the state of Iowa's reimbursement rules and regulations.
*Third-Party liability, where a private insurance company or another payer was the primary payer and Medicaid was
billed instead.
Examples of healthcare fraud you might encounter in your work are:
1) turning hours in for billing that were not worked
2) logging one activity when a different one was actually done
3) working with the person served on activities not covered by their annual plan.
Question 5: If my service documentation does not accurately reflect what a person served and I worked on during service delivery time it could be considered healthcare fraud, waste or abuse.