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Medicare Audit & Compliance Tools - Medicare Appeals - CMS Program Integrity Resources

To report Medicare fraud, please contact the Office of Inspector General at (800) 447-8477 or HHSTips@oig.hhs.gov

CMS defines 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.
 
Recent developments in whistleblower suits (where an individual may report Medicare fraud) filed in conjunction with the Department of Justice and Office of the Inspector General provide little doubt about the government's absolute intent to crack down on perceived fraud.  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)
• Provider completing Certificates of Medical Necessity (CME) for patients not known to the provider
• Suppliers completing CMEs for the physician
• Using another person's Medicare card to obtain medical care

CMS Definition - Medicare Abuse

CMS defines Abuse as 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.
 
The majority of healthcare provider "errors" fall within the CMS definition of Abuse.  As such, significant financial penalties and additional potential exposure to fraud claims may follow CMS actions in these matters.  Examples of abuse include, but are not limited to the following:

• Excessive charges for services or supplies
• Claims for services that don't meet CMS medical necessity criteria 
• Breach of the Medicare participation or assignment agreements
• Improper billing or coding practices

Penalties for Medicare Fraud & Abuse

Medicare fraud and abuse cases are routinely referred to the Office of Inspector General (OIG). The OIG has the authority to use civil monetary penalty, criminal penalty, or administrative sanctions in connection with these cases.  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