Compliance: Know the Difference Between Fraud and Abuse

Why This Topic Matters

Understanding the difference between fraud and abuse helps organizations strengthen compliance programs, reduce payment risk, and recognize issues that can trigger audits, repayment demands, or enforcement action.

Article Sections

1. What Constitutes Medicare Fraud?

   Defines fraud at a high level and discusses broad examples of intentional deception in the Medicare program. It also notes that fraudulent activity can involve multiple types of individuals and organized schemes.

2. Fraud varieties

   Summarizes several broad categories of fraudulent conduct described in the source material. The section focuses on general patterns of misconduct and enforcement concerns.

3. Gang visits

   Describes a form of abusive or fraudulent behavior involving group billing in long-term care settings. The discussion frames the compliance concern in a general way.

4. Here’s How Abuse Is Different Than Fraud

   Explains abuse as a separate Medicare compliance issue that is more closely tied to claims, billing, and coding practices. It highlights the risk that improper practices can escalate.

5. Top abuse scenarios

   Outlines broad examples of abusive billing and coding behaviors identified by the source. The section also includes payer-order and patient-charge concerns, along with related compliance topics.

6. Example: Unbundling

   Provides a general illustration of unbundling in a laboratory billing context. The example is presented to show why the practice is a compliance concern.

7. Resource

   Points readers to CMS educational material for additional background on fraud and abuse. It serves as a reference and follow-up section.