Page 120 - 2020 ARE eGuide for Clinical at Nonhospital Sites

Fraud, Waste, and Abuse

There are many laws and regulations that
apply to health care organizations. Both
the federal and state governments
regulate healthcare.
Many national investigations have taken
place over the past few years. The
investigations use the resources of the
federal and state governments, such as
the State Attorney and the FBI.

A number of the investigations center upon the complicated regulations regarding filing
claims for payment of services.

Recently, quality of care has become another focus of investigators.
Fraud is an intentional act in violation of a law, rule, or regulation that is done
knowingly, willfully, and intentionally and results in a benefit to the person or
business.

Fraud involves intent and knowledge, whereas there is no evidence of intent with waste or
abuse. This is the primary difference between fraud, waste, and abuse.