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Fraud and Abuse

Fraud: An intentional (willful or purposeful) deception or misrepresentation made by a person with the knowledge the deception could result in some unauthorized benefit to themself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.  Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal healthcare payment for which no entitlement would otherwise exist; Knowingly soliciting, receiving, offering, or paying remuneration (e.g., kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by Federal healthcare programs.

Abuse: Practices inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to government programs, or in seeking reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for healthcare.

The difference between “fraud” and “abuse” depends on specific facts, circumstances, intent, and knowledge,

Medicare Fraud and Abuse Laws Federal laws governing Medicare fraud and abuse include the:

  • False Claims Act (FCA)
  • Anti-Kickback Statute (AKS)
  • Physician Self-Referral Law (Stark Law) The Stark law prohibits a physician from referring Medicare patients to certain entities with which the physician – or their immediate family member – has a prohibited financial relationship. The Stark law applies only to certain types of services – referred to in the statue as “designated health services” – and hospice is not on that list. This applies only to hospice and not a hospices other lines of business.
  • Social Security Act, which includes the Exclusion Statute and the Civil Monetary Penalties Law (CMPL)
  • United States Criminal Code

ENTITIES

CMS Center on Program Integrity (CMS CPI)

The mission of the CMS CPI is to detect and combat fraud, waste, and abuse of the Medicare and Medicaid programs.  They focus on making sure CMS is paying the right provider for the right amount of services covered under Medicare and Medicaid programs.  They work with providers, states, and other stakeholder to support proper enrollment and accurate billing practices.

CPI | CMS

Office of Inspector General (OIG) The mission of the Office of Inspector General (OIG) is to protect the integrity of the Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.

Unified Program Integrity Contractors (UPIC)

UPICs perform numerous functions to detect, prevent, and deter specific risks and broader vulnerabilities to the integrity of the Medicare and Medicaid programs. They will also coordinate activities with CMS and other agencies at the federal, state, and local government levels, as well as with other CMS partners and contractors.

Medicaid Fraud Control Units (MFCUs) 

Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as abuse or neglect of residents in health care facilities and board and care facilities and of Medicaid beneficiaries in noninstitutional or other settings. MFCUs operate in each of the 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. MFCUs, usually a part of the State Attorney General’s office, employ teams of investigators, attorneys, and auditors; are constituted as single, identifiable entities; and must be separate and distinct from the State Medicaid agency.

Reporting Fraud

To protect patients served, as well as their agency, hospices should have in place current policies and procedures regarding fraud reporting, which includes staff education. Policies and procedures should be reviewed and updated on a periodic basis.

Watch a brief video on How to Report Medicare Fraud to the OIG and learn how you can report these activities anonymously to the Office of the Inspector General. This video is part of the OIG Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training initiative to prevent fraud, waste, and abuse. Created in 2011, all the information is current.

Submit a Hotline Complaint | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services (hhs.gov)

Fraud can also be reported anonymously to a State Attorney General’s office

Subregulatory Guidance