Fraud and Abuse


Also found in: Acronyms.
A pair of unethical and potentially illegal acts that can get a physician or other health care provider into trouble:
• Fraud—the deliberate billing for a service that was never given or for a service that has a higher reimbursement than the service produced
• Abuse—payment for items or services that are billed by mistake by providers, but should not be paid for by Medicare
References in periodicals archive ?
HIPAA clearly marked a substantial step toward fulfilling Shalala's vision of a "capacity, and preferably a systemic strategy" in the area of health care fraud and abuse, and it addressed the two requirements for effective fraud control--sustained investment in management and careful oversight of the programs (Kettl 1998).
To fuel the expansion, the government has hired hundreds of new agents to investigate health care fraud and abuse, pursuant to the 1996 Health Insurance Portability and Affordability Act (HIPAA).
The occupational fraud and abuse report, mentioned previously, found that small businesses are the most vulnerable to fraud abuse.
Rule-Based Supervised Models Simple, known fraud Generalize among complex and abuse types only fraud and abuse types Expert knowledge Historical claims data and a set of known fraud and abuse suspects Embody knowledge Embody experience Nonadaptive, relatively Requires historical examples easy to circumvent of fraud/abuse Rule-Based Unsupervised Models Simple, known fraud New, previously unknown and abuse types only types of fraud and abuse Expert knowledge Historical claims data Embody knowledge Enable discovery Nonadaptive, relatively Detects patterns that are novel, easy to circumvent but not necessarily fraud
Estimates are that up to 10 percent of public health care expenditures are related to fraud and abuse. But not anymore -- not in the Florida Medicaid program, at any rate.
The CCH Health Care Fraud and Abuse Guide incorporates CCH's expertise in tracking and in explaining and analyzing business law, including CCH Medicare and Medicaid Guide, which has covered the entitlement program since its inception in 1965.
While these types of fraud and abuse are hard to prove, hospital utilization review personnel have cited numerous anecdotal examples across a wide variety of hospitals in Florida.
The Affordable Care Act--one of the health reform laws--gives government agencies new enforcement powers and new funding to go after fraud and abuse and physicians may find themselves under increased scrutiny as a result.
Health care fraud and abuse; practical perspectives, 2006 cumulative supplement.
Small businesses are the most vulnerable to occupational fraud and abuse and suffer disproportionately larger losses as a result, according to the 2004 "Report to the Nation on Occupational Fraud and Abuse" prepared by the Association of Certified Fraud Examiners.