Fraud and Abuse - JF Part A

Medicare fraud and abuse are in the national spotlight. The U.S. General Accounting Office estimates that $1 out of every $10 spent for Medicare and Medicaid is lost to fraud. This translates into fewer resources for people who depend on these programs. Noridian has a team devoted to combating fraud and abuse. Our Benefit Protection team is ready to investigate any problems that you report.

Reporting Fraud and Abuse

If you suspect fraud or abuse, please collect the following information and mail it to us:

• Date of service and name of the beneficiary
• Name of the physician and/or supplier
• Complete description of the problem
• Any documentation you have that is related to the situation
• Name, address and phone number of the person making the complaint if it is someone other than the beneficiary

See the Fraud and Abuse/Benefit Protection address on the Mailing Addresses webpage.

Fraud

Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person. The most frequent kind of fraud arises from a false statement or representation that is material to entitlement or payment under the Medicare program. The violator may be a practitioner, physician supplier, contractor employee or beneficiary. Examples of fraud include, but are not limited to the following:

• Billing for services or supplies that weren't provided
• Altering claims to obtain higher payments
• Soliciting, offering or receiving a kickback, bribe or rebate (example: Paying for referral of clients)
• Using another person's Medicare card to obtain medical care

Abuse

In general, abuse describes behaviors or practices of providers, physicians, or suppliers of services and equipment that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business, or fiscal practices. The practices may, directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or which are medically unnecessary. Examples of abuse include, but are not limited to the following:

• Excessive charges for services or supplies
• Claims for services that aren't medically necessary
• Breach of the Medicare participation or assignment agreements
• Improper billing practices

Penalties for Fraud and Abuse

Fraud and abuse cases are routinely referred to the Office of Inspector General (OIG) for decisions on punishment. The OIG could use civil monetary penalty, criminal penalty, or administrative sanctions. Civil monetary policies may be imposed in the following cases, but may also be applied to other cases:

• An item or service is not provided as claimed
• An item or service claimed is false or fraudulent
• The Medicare assignment provisions are violated
• An item or service is provided by an excluded person

Criminal penalties may be imposed in the following cases, but may also be applied to other cases:

• Soliciting, offering or receiving a kickback, bribe or rebate
• Knowingly and willingly making or causing to be made any false statement or misrepresentation in applying for a Medicare benefit or payment

Administrative sanctions may be used:

• Against an abusive practitioner/provider/supplier
• Against a practitioner/provider/supplier who consistently fails to comply with Medicare regulations

When a provider has committed Medicare fraud, or a new scam is identified, the OIG may issue a National OIG Fraud Alert to Medicare carriers and intermediaries, law enforcement, private insurers and other government agencies. These alerts allow these organizations to investigate whether the same provider or scam is operating in their jurisdictions. In addition, once (CMS has identified a Medicare scam or fraudulent scheme operating in multiple states, it will issue a CMS Medicare Fraud Alert. CMS has two levels of fraud alert, Unrestricted and Restricted. Unrestricted Alerts provide information regarding a scheme, but do not identify any specific providers. Restricted Alerts describe the scheme and specify suspected providers and/or entities. Both types of alerts are available at the CMS website.