What is fraud waste and abuse?

Fraud, waste and abuse (FWA) is defined as "the intentional misreporting, miscoding, self-dealing, or other fraudulent or dishonest practices that result in unnecessary costs to the Medicare program."

There are many ways that providers can commit fraud against the Medicare program. Some common examples include:

• Billing for services that were not provided
• Upcoding (billing for a more expensive service than the one that was actually provided)
• Unbundling (billing for each component of a procedure separately instead of billing for the procedure as a whole)
• Double-billing (billing for the same service more than once)
• Inflating charges
• Creating false claims

These are just a few examples of the many ways that providers can commit fraud against the Medicare program. If you suspect that someone is committing fraud, waste or abuse against Medicare, you can report it to the Centers for Medicare & Medicaid Services (CMS).

Medicare Fraud Waste and Abuse Training

Fraud waste and abuse training is a critical part of any organization's compliance program. It is important for employees to understand what constitutes fraud, waste and abuse, and how to report it. Training should be conducted on a regular basis, and updated as new laws and regulations are enacted.

Fraud, waste and abuse can have a significant financial impact on an organization. It is estimated that fraud, waste and abuse cost the U.S. government billions of dollars each year. In addition to the monetary loss, fraud, waste and abuse can damage an organization's reputation and credibility.

Fraud, waste and abuse training should be conducted by qualified trainers who are familiar with the relevant laws and regulations. The training should be interactive and allow employees to ask questions and get clarification on points they do not understand. Employees should be given ample opportunity to practice what they have learned so that they can apply it in the workplace.

Organizations should consider using fraud, waste and abuse training as part of their new employee orientation program. This will help ensure that all employees are aware of the organization's policies and procedures from the start. In addition, all employees should be required to sign a statement indicating that they have received and understand the training.

Fraud, waste and abuse training is an important part of any compliance program. By providing employees with the knowledge and tools they need to identify and report fraud, waste and abuse, organizations can help protect themselves from the financial and reputational damage that it can cause.

Glossary:

Medicare advantage:

A type of health insurance plan offered by a private company that contracts with Medicare to provide benefits to Medicare beneficiaries

Creditable coverage: health insurance coverage that meets the standards set by the Centers for Medicare and Medicaid Services (CMS) and can be used to satisfy the requirement to have creditable coverage

Part D: the prescription drug benefit under Medicare

Open enrollment: the period each year when people can enroll in or change their health insurance coverage

COBRA: the Consolidated Omnibus Budget Reconciliation Act, which provides employees and their families with the ability to continuation of group health insurance coverage under certain circumstances, such as loss of employment

Fraud: a deliberate misrepresentation of facts in order to deceive someone

Waste: the use of resources in a manner that is not productive or efficient

Abuse: the improper use of something, often resulting in damage or harm

Prevent fwa: take action to stop something from happening or to keep it from getting worse. Also known as "fraud mitigation" or "fraud prevention"

Compliance: the act of following a set of rules or guidelines

Non-compliance: failure to follow a set of rules or guidelines

Policy: a set of principles that govern decision making within an organization

Procedure: a set of specific steps that must be followed in order to complete a task

Standard: a level of quality or achievement that is considered acceptable

Audit: an examination of an organization's financial statements by an independent auditor

Investigation: a process of gathering facts and evidence to determine if a crime has been committed or if someone has violated a rule or regulation

Sanction: a penalty or other action that is taken against an individual or organization for violating a rule or law

Civil penalty: a monetary fine that is imposed as a punishment for violating a civil law

Criminal penalty: a punishment that is imposed for breaking a criminal law and can include incarceration, probation, or fines

Whistleblower: an individual who reports illegal or unethical behavior to the authorities

Retaliation: any action taken against an individual for reporting fraud, waste or abuse that is intended to punish or deter the individual from coming forward

False claim: a claim for payment that is known to be false or fraudulent

Kickback: a payment made in exchange for referral of business or for other favored treatment

Gift: anything of value given without expectation of anything in return

Conflict of interest: a situation in which an individual has a financial or other personal interest that could influence his or her ability to make objective decisions

Stark law: a federal law that prohibits physicians from referring patients for certain health services to an entity with which the physician or immediate family member has a financial relationship, unless an exception applies

Anti-kickback law: a federal law that prohibits the exchange of anything of value in order to induce referrals for health services that are reimbursed by federal health care programs

False statement: a statement that is knowingly false or made with reckless disregard for the truth

Falsification: the act of altering or changing something so that it is not accurate or true

Billing fraud: the act of submitting false claims to Medicare or Medicaid for payment

Coding fraud: the act of billing for services using codes that are not appropriate for the services that were actually provided

Identity theft: the act of using another person's identity to defraud Medicare or Medicaid

Provider fraud: the act of submitting false claims for payment to Medicare or Medicaid

Patient fraud: the act of defrauding Medicare or Medicaid by enrolling in the program when you are not eligible, or by using someone else's identity to receive benefits

Drug diversion: the act of illegally obtaining and distributing prescription drugs

Medical necessity: a determination by a health care provider that a particular service, treatment or test is necessary for the diagnosis or treatment of a patient's medical condition

Upcoding: the act of billing for a more expensive service than the one that was actually provided

Unbundling: the act of billing for individual components of a service that are usually billed together as a single service

Double billing: the act of billing for the same service more than once

Misrepresentation: the act of making a false or misleading statement

Fraudulent inducement: the act of misrepresenting or omitting material information in order to convince someone to enter into a contract

False certification: the act of certifying that something is true when it is not, or of certifying that a requirement has been met when it has not

Bid rigging: the act of colluding with other bidders to submit artificially high or low bids, or to otherwise rig the bidding process

CMS requirements: the Centers for Medicare and Medicaid Services' (CMS) requirements for eligibility, coverage and payment

Physician self-referral law: a federal law that prohibits physicians from referring patients for certain health services to an entity with which the physician or immediate family member has a financial relationship, unless an exception applies

Eligibility requirements: the requirements that an individual must meet in order to be eligible for Medicare or Medicaid benefits

Credentialing: the process of verifying that a health care provider meets the qualifications to provide care

Prior authorization: the process of getting approval from Medicare or Medicaid before providing certain services

fwa training: the process of completing a fraud, waste and abuse (FWA) training program

ZPIC: a Zone Program Integrity Contractor, which is an organization that contracts with CMS to help prevent and detect fraud, waste and abuse in the Medicare and Medicaid programs

OIG: the Office of Inspector General, which is responsible for investigating allegations of fraud, waste and abuse in the Medicare and Medicaid programs

RAC: a Recovery Audit Contractor, which is an organization that contracts with CMS to help identify overpayments and underpayments in the Medicare and Medicaid programs

MAC: a Medicare Administrative Contractor, which is an organization that contracts with CMS to process and pay claims for Medicare benefits

MFCU: a Medicaid Fraud Control Unit, which is a state-level organization that investigates and prosecutes Medicaid fraud cases

FBI: the Federal Bureau of Investigation, which is responsible for investigating allegations of health care fraud that cross state lines

Training requirements: the requirements that an individual must meet in order to be eligible for Medicare or Medicaid benefits

Fraud waste and abuse training

Course overview:

The Fraud, Waste, and Abuse Training course is designed to provide employees with the knowledge and skills they need to prevent, detect, and report instances of fraud, waste, and abuse in their workplace.

The course covers a variety of topics, including:

• Overview of fraud, waste, and abuse laws and regulations

• Identification of potential fraud, waste, and abuse red flags

• Appropriate reporting procedures for instances of fraud, waste, or abuse

• Investigation and resolution process for instances of fraud, waste, or abuse

Upon completion of this course, employees will be able to:

• Understand what constitutes fraud, waste, and abuse

• Identify potential red flags for fraud, waste, and abuse

• Understand the appropriate reporting procedures for instances of fraud, waste, or abuse

• Understand the investigation and resolution process for instances of fraud, waste, or abuse.

This course is designed for all employees.

Course Objectives:

By the end of this course, employees will be able to:

• Understand what constitutes fraud, waste, and abuse

• Identify potential red flags for fraud, waste, and abuse

• Understand the appropriate reporting procedures for instances of fraud, waste, or abuse

• Understand the investigation and resolution process for instances of fraud, waste, or abuse.