What Is Health Care Fraud and Abuse?
Fraud and abuse can take many forms. Below are common examples:
- Upcoding: Billing for a more expensive service than provided
- Services Not Rendered: Charging for services that were never given
- Excessive Units and Visits: Billing for more services than medically necessary
- Billing Under Another Provider’s ID: Using someone else’s ID number or National Provider Identifier
- Incorrect Coding: Using the wrong billing codes or combining codes improperly
- Unbundling: Separating services that should be billed together
- Unauthorized Providers: Billing for care provided by non-licensed providers
- Double Billing: Charging twice for the same service
- Misrepresenting Level of Care: Claiming a higher level of care than provided
- Patient Overload: Billing for an excessive number of patients in one day
- Misusing Modifiers: Applying billing modifiers incorrectly
- Lack of Documentation: Failing to document medical necessity
- Over/Underutilization: Providing too much or too little care
- Billing for No-Shows: Charging for canceled or missed appointments
- Falsifying Records: Altering clinical notes or documents
- Forgery: Faking signatures or records
How to Report Health Care Fraud and Abuse
If you see any activity that may be fraudulent, wasteful or non-compliant, we strongly encourage you to call our Compliance and Ethics Hotline at 1-855-507-1805 (TTY 711). Not sure if it’s fraud or abuse? Let us know below. Reports can be made anonymously — no detail is too small to review.
Compliance and Fraud, Waste and Abuse Reporting Form
This confidential form has instructions on how to fill it out and where to send it. You do not have to give your name to report suspected fraud or abuse.Medicare Learning Network FWA Training
Use the Medicare Learning Network web-based training online here.Medicare Fraud and Abuse: Prevent, Detect, Report
View the Medicare Learning Network publication on fraud and abuse definitions, laws, how to report suspected fraud and physician business relationships that may raise concerns.CMS Fraud Handbook
Learn about detecting and preventing fraud in Medicare Part C and D here.