Question

In: Nursing

Differentiate between fraud and abuse, making sure to provide an example of each. Does one occur...

Differentiate between fraud and abuse, making sure to provide an example of each. Does one occur more frequently in the medical office, and if so, why? How would you report this illegal activity?

Solutions

Expert Solution

The fact is quite evident that fraud and abuse take a severe toll on the Medicare and Medicaid programs and cost them a significant amount of money every year. To be precise fraud and abuse are two different practices.

Fraud generally refers to intentionally misrepresenting the facts so as to gain wrongful benefit from the health care services. Some examples of fraud in healthcare services are:-

1) Misrepresentation of medical records and altering details of service rendered.

2) Altering the medical bills

3)Presenting false claims regarding eligibilty.

On the other hand abuse generally refers to actions that are inappropriate and inconsistent and generally falls outside the perimeter of acceptable standards of healthcare practices. Abuse can result in cost that are medically unnecessary. Some examples of abuse are:-

1)Inability or failure to maintain necessary medical records.

2) Failure to furnish medical bills or records when asked for.

3) Billing for medical services that are unnecessary.

Both fraud and abuse both cause serious impact to the health care services. But,often the fraud is considered to be practiced more frequently because the act of fraudulent is committed willfully to gain certain advantage. On the other hand abuse is considered an unintentional practice.

In order to report a case of fraud and abuse we must possess certain information before hand like when the act was committed and who committed the act. Methods to report fraud or abuse:-

1) By phone call to Health And Human Service Office Of the Inspector General

2) We can report online by visiting the website of Health and Human Service Office Of the Inspector General.

3) By Fax of maximum 10 Pages

4)By mailing Office of the Inspector General


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