Compliance: Understand How Fraud and Abuse Are Different

Why This Topic Matters

Understanding the difference between fraud and abuse helps healthcare organizations recognize compliance risk, strengthen billing integrity, and avoid practices that can lead to improper payments or enforcement action.

Article Sections

1. What Constitutes Medicare Fraud?

   Introduces the fraud side of Medicare compliance and describes broad categories of intentional misconduct discussed in Medicare contractor materials.

2. Gang visits

   Explains a particular fraud scenario involving services billed in connection with nursing home visits and resident populations.

3. Here’s How Abuse Is Different Than Fraud

   Summarizes the abuse side of Medicare compliance and the types of billing and claims practices that may create improper payment risk.

4. Example

   Provides a broad illustrative discussion of one billing practice highlighted by the Medicare contractor as a compliance concern.