Page 121 - 2020 ARE eGuide for Clinical at Nonhospital Sites

Here are some examples of fraud:
• Knowingly billing for services that were not actually furnished
• Signing blank records for use in submitting claims
• Falsifying information on records
• Offering incentives to Medicare patients to receive services
• Offering payment in exchange for referral of patients
• Knowingly billing for medically unnecessary services

Abuse

Abuse is a violation that results in some
kind of benefit such as a payment to
the individual or organization and
unnecessary costs to insurers.
Some examples of abuse are:
• Misusing codes on a claim
• Charging excessively for services or supplies
• Billing for services that were not medically
necessary

Waste
Waste means practices that either directly or indirectly
result in unnecessary cost to insurers.
Some examples of waste are:
• Overutilization of services
• Performing a more expensive test when a less expensive test would
be appropriate
• Providing services that are not based upon medical necessity or
evidence based standards