What is the difference between Medicare fraud and abuse?

On Behalf of | Jan 21, 2022 | Medicare and Medicaid Fraud

Health care providers must take certain steps to ensure Medicare claims are legitimate. Failure to do so leads to lost funds, which affects patients as well as hospitals, clinics, and other health care centers.

You should also have a good understanding of the difference between Medicare fraud and abuse. This guide explains a few of the key details to keep in mind to protect yourself.

Medicare fraud vs. abuse

When it comes to Medicare fraud, it is important to differentiate the practice from improper payments. Examples of Medicare fraud include billing a patient for services that were not actually provided, billing a patient for an appointment they did not actually attend, billing for unnecessary services, or using the wrong billing code to increase costs.

While similar to fraud, Medicare abuse usually entails taking actions that cost the program more than necessary, while also decreasing the quality of care received by the patient. Compliance officials determine abuse by comparing the quality of the care provided to the standards all other doctors and medical providers must follow.

How to prevent them at your practice

Fortunately, there are lots of steps your clinic can take to avoid fraud and abuse and remain compliant with all pertinent guidelines. Having a compliance professional within your organization ensures that any oversights or issues become apparent immediately. Your compliance professionals should also work from written documentation that clearly defines appropriate procedures.

Employee training is another crucial component of avoiding fraud and abuse. Make sure your staff is up-to-date on all rules and regulations. Regular monitoring and auditing of your prevention system should also take place, which will ensure it continues to offer the same protection.


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