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Fraud and Abuse

Medicare fraud is typically characterized by one or more of the following:
  • Knowingly submitting false statements or making misrepresentations of fact to obtain a federal healthcare payment for which no entitlement would otherwise exist.
  • Knowingly soliciting, paying, and/or accepting remuneration to induce or reward referrals for items or services reimbursed by Federal healthcare programs.
  • Making prohibited referrals for certain designated health services.
Medicare fraud can be committed by individuals or by an institution or group. Examples of Medicare fraud include:
  • Knowingly billing for services not furnished, supplies not provided, or both, including falsifying records to show delivery of such items.
  • Billing Medicare for appointments that the patient failed to keep.
  • Knowingly billing for services at a level of complexity higher than the service actually provided or documented in the file.