What is the definition of Fraud and Abuse?
Fraud is defined as an intentional deception or misrepresentation with the knowledge that the deception could result in some unauthorized benefit to a person or an entity. Abuse is defined as incidents or practices that are inconsistent with accepted, sound business, fiscal or medical administrative practices. While true fraud involves only a small percentage of individuals, the costs associated with it are high. Suspicious activity exists when there is a reasonable belief that fraud or abuse may have occurred. Examples of Provider Fraud: • Billing for services not rendered • Altering medical records • Use of unlicensed staff Drug diversion • Kickbacks and bribery Examples of Member Fraud: • Falsification of information • Forging or selling prescription drugs • Using transportation benefit for non-medical related business • Adding an ineligible dependent to the plan • “Loaning” or using another’s insurance card Examples of Broker and Agent Fraud: • Alteration of documents • Bribery and
