What are health care fraud and abuse?

As a health care practitioner in Texas, administrative concerns often take a back seat to what you rightly consider the most important aspect of your job: your patients’ well-being. Yet issues with those administrative tasks can often lead to issues that may threaten your ability to support that.

A common issue that professionals in the health care industry deal with the potential for fraud and abuse. Indeed, regulators expend a great deal of time and resources in preventing them. The words “fraud” and “abuse” may seem overly general (thus leading you to worry that regulators might apply infractions related to them liberally). Fortunately, federal guidelines clearly define these terms (allowing you to easily compare those definitions to your actions).

Defining fraud

As you know, in the health care industry, many entities look to Medicare to establish precedence for regulations. According to the Centers for Medicare and Medicaid Services, “fraud” includes:

  • Knowingly submitting, prompting or allowing the submission of false claims for payment
  • Knowingly receiving, paying, soliciting or offering financial kickbacks to induce or reward referrals for services compensated by insurance payers
  • Knowingly making referrals for prohibited health services

You likely noticed a common word associated with each infraction: knowingly. Prosecutors who seek to bring health care fraud charges against you must show that you intentionally allowed fraudulent actions to occur.

Defining abuse

Similarly, CMS defines “abuse” as actions that directly or indirectly lead to unnecessary costs submitted to insurance payers. This may include performing (and billing for) services that a payer may not consider medically necessary. In such a scenario, your clinical judgment (combined with your knowledge of your patient’s individual circumstances) may help to answer accusations of abuse made by an insurance payer.