Question

Insurance fraud and abuse may be involved in more than 10% of submitted medical claims. Discuss with your classmates the difference between fraud and abuse. Provide examples of both.

Answer 1

The difference between fraud and abuse comes down to the individual's purpose. The two exercises have a similar impact: they devour important assets from the Medicare Trust Fund.

Health care manager might deal with this issue by overhauling the billing mechanism and linking them to the actual services so that the bills are generated automatically based on the actual service provided.

Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment. Health care fraud is a crime.

Examples of Fraud:-

• misrepresenting dates, frequency, duration or description of services rendered
• billing for services at a higher level than provided or necessary
• falsifying eligibility.
• failing to disclose coverage under other health insurance.

Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.

Examples of Abuse:-

• a pattern of give up cost-shares or deductibles
• failure to maintain adequate medical or financial records
• a pattern of claims for services not medically necessary
• refusal to furnish or allow access to medical records improper billing practices