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In the case of medical fraud and abuse ignorance is not bliss. Your "honest mistake" could lead to a situation that put you the health care provider or you the medical biller at risk for investigation of fraud, waste, or abuse if it continues and is not checked.
Since a simple mistake can be considered fraud; I thought it would be timely to discuss in this week's newsletter as a reminder what is considered by the Office of Inspector General to be fraud and/or abuse and to briefly state the differences.
First of all, fraud can occur when deception is used in a claims submission to obtain payment from the payer. A person who knowingly submits a false claim to benefit themselves or others commits fraud. Fraud can also be interpreted from mistakes that result in excessive reimbursement. Unfortunately, no proof of "specific intent to defraud" is required for fraud to be considered.
Second, abuse means incidents or practices by physicians, not usually considered fraudulent, but are inconsistent with accepted sound medical business or fiscal practices.