Question

Give examples of how healthcare managers can deal with fraud and abuse

Answer 1

Fraud is defined as knowingly, and willfully executes or attempts to execute a scheme…to defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses, representations, or promises any of the money or property owned by…any healthcare benefit program. Abuse is most often defined in terms of acts that are inconsistent with sound medical or business practice. Unlike fraud, abuse is an unintentional practice that directly or indirectly results in an overpayment to the healthcare provider. Abuse is similar to fraud, except that the investigator cannot establish the act was committed knowingly, willfully, and intentionally. Use of the term “intentional” is important in defining fraud and abuse and in identifying ethical or unethical action. .