Health Care Fraud and Abuse

1367 Words6 Pages
Health care Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment. Some examples of health care fraud are failing to disclose coverage under other health insurance, falsifying eligibility, billing for services at a higher level than provided or necessary, misrepresenting dates, frequency, duration, or description of services rendered, falsifying claims or medical records, or submitting claims for services not provided or used. Health care Abuse is actions that are improper, inappropriate, outside of acceptable standards of professional conduct or medically unnecessary. Some examples of health care abuse are failure to maintain adequate medical or financial records, refusal to furnish or allow access to medical records, improper billing practices, and patterns of waiving cost-shares or deductibles or a pattern of claims for services not medically necessary. (HealthNet) Health care abuse generally involves an “innocent” mistake, where health care fraud generally involves some sort of error a party has close knowledge of. The main difference between health care fraud and abuse is the intent of the actions. Penalties for health care fraud and abuse are assessed against the provider, not the individual employees. The provider is the entity that has benefited from collection of the fraudulent payment. Risk area for coding fraud can include, assigning a code for a higher level of services than the services actually provided, assigning a code for a “covered” services when the service actually provided is “non-covered”, assigning codes for diagnoses that re not present or for procedures that were not performed, assigning separate codes for each component of a comprehensive services to increase reimbursement (unbundling) and discrepancies between the physicians and the hospital’s codes for the same patient
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