What Does Medicare Error, Abuse and Fraud Look Like?

Medicare Errors

Mistakes made without intending to cause harm. Errors are often found on a beneficiary’s Statement of Benefits as:

n incorrect charges;

n Services that were not performed and/or are miscoded on the bill.

Examples of Errors:

An 89 year old man who has been billed for a pregnancy test.

Medicare Abuse

Incidents or practices on the part of providers that are inconsistent with accepted sound medical, business, or fiscal practices. These practices may directly or indirectly result in:

• unnecessary costs to the program

• improper payment

•

The difference is intention!

payment for services that fail to meet professionally recognized standards of care or payment for services that are determined medically unnecessary.

Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented the facts to obtain payment.

Examples of Abuse

n Claims for services that are not medically necessary.

n Billing for a higher level of services than were actually performed.

n Services that were not delivered at all.

n Intentional deception or misrepresentation of services or benefits covered by Medicare and/or Medicaid.

n Unauthorized benefits paid to providers and resulting in unnecessary costs to Medicare and/or Medicaid.

n Intentional deception or misrepresentation of services or benefits covered by Medicare and/or Medicaid.

n Unauthorized benefits paid to providers and resulting in unnecessary costs to Medicare and/or Medicaid.

n Intentional deception or misrepresentation of services or benefits covered by Medicare and/or Medicaid.

n Unauthorized benefits paid to providers and resulting in unnecessary costs to Medicare and/or Medicaid.

Fraud

Intentional deception or misrepresentation of services or benefits covered by Medicare and/or Medicaid resulting in unauthorized benefits paid to providers and resulting in unnecessary beneficiary and programmatic costs.

Examples of Fraud

n Billing for services not provided. Billing non-covered services as covered services.

n Beneficiaries receiving medical supplies they don’t need.

n Billing for unnecessary rehabilitation services.

n Inappropriate diagnosis codes to increase Medicare reimbursement.

n Ambulance transportation of multiple patients and billing for each passenger.

n Billing for diagnostic tests for deceased patients.

n Kickback schemes

n Offering free tests and then asking for a Medicare card