decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Fraud and Abuse / Overview
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Article Overview
This article explains the general Medicare fraud and abuse oversight landscape and the government entities involved in detecting, investigating, and addressing improper billing activity. It also discusses patient-reporting incentives, whistleblower actions, and the shift of former Medicare Carrier Manual material into the Program Integrity Manual. The content is relevant to coders, compliance staff, billing teams, auditors, and anyone monitoring Medicare program integrity guidance.
Why This Topic Matters
Fraud and abuse enforcement affects Medicare billing compliance, audit risk, and provider exposure to administrative, civil, and criminal action. Understanding the agencies, manuals, and reporting framework helps organizations recognize where oversight responsibility sits and how related guidance is organized.
What You Will Learn
- How Medicare fraud and abuse oversight is generally structured
- Which agencies are involved in initial detection and referral
- How patient reporting and whistleblower concepts fit into program integrity
- Where legacy Medicare manual guidance is now maintained
Who Should Read This
- Medical coders
- Compliance officers
- Billing personnel
- Practice managers
- Healthcare auditors
- Revenue cycle staff
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