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What's the difference between fraud, waste and abuse when it comes to health care? What is the government doing to prevent fraud, waste and abuse from happening? Learn the definitions and differences in these legal terms and how CMS has worked to prevent these from happening since its inception in 1965.
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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”
