Fraud, Waste & Abuse in Health Care

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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

  1. 1. Fraud, Waste & Abuse in Health Care
  2. 2. Definitions
  3. 3. DefinitionsTerms have legal significance
  4. 4. Definitions Fraud
  5. 5. Definitions FraudAction: Knowingly making a false statement or claim
  6. 6. Definitions FraudAction: Knowingly making a false statement or claimResult: Funding unauthorized benefit
  7. 7. Definitions FraudExample: Filing a claim on services that were never performed
  8. 8. Definitions Waste
  9. 9. Definitions WasteAction: Misuse or overuse of resources
  10. 10. Definitions WasteAction: Misuse or overuse of resourcesResult: Funding unnecessary costs
  11. 11. Definitions WasteExample: Writing high-cost prescriptions over less expensive generic prescriptions
  12. 12. Definitions Abuse
  13. 13. Definitions AbuseAction: Improper use of info or documentation
  14. 14. Definitions AbuseAction: Improper use of info or documentationResult: Funding for personal gain without evidence of criminal intent
  15. 15. Definitions AbuseExample: 99215 E/M for one hour when the visit was actually only 15 minutes
  16. 16. How prevalent isfraud & abuse inU.S. health care?
  17. 17. In 2011, $98 billion was lost due toMedicare/Medicaid fraud & abuse
  18. 18. What is thegovernment doing to prevent fraud & abuse?
  19. 19. Title XIX to SSA1965
  20. 20. Anti-Fraud & Abuse AmendmentsTitle XIX to SSA1965 1977
  21. 21. False Claims Act Anti-Fraud & Abuse AmendmentsTitle XIX to SSA1965 1977 1986
  22. 22. HIPAA False Claims Act Anti-Fraud & Abuse AmendmentsTitle XIX to SSA1965 1977 1986 1996
  23. 23. HIPAA False Claims Act Anti-Fraud & Abuse AmendmentsTitle XIX to SSA Deficit Reduction Act1965 1977 1986 1996 2005
  24. 24. HIPAA Healthcare Fraud False Claims Act Prevention & Enforcement Action Team (HEAT) Anti-Fraud & Abuse AmendmentsTitle XIX to SSA Deficit Reduction Act1965 1977 1986 1996 2005 2009
  25. 25. Meaningful Use American Recovery &Reinvestment Act/ HITECH2009
  26. 26. Affordable Care ActMeaningful Use American Recovery &Reinvestment Act/ HITECH2009 2010
  27. 27. Affordable Care ActMeaningful Use American Recovery & Center for ProgramReinvestment Integrity Act/ HITECH2009 2010
  28. 28. Healthcare Reform OIG Releases Affordable Care Act Report on E/Ms & EHRsMeaningful Use American Recovery & Center for ProgramReinvestment Integrity Act/ HITECH2009 2010 2012
  29. 29. Want to learn more aboutfraud & 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”

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