Fraud, Waste, and Abuse Detection and Prevention
Distinguishing the three
Fraud is intentional deception for gain; waste is misuse of resources without intent; abuse is conduct inconsistent with sound practice that may be unintentional. Reviewers must recognize red flags: services never rendered, upcoding, unbundling, duplicate claims, impossible volumes or geography, beneficiaries who deny receiving services, and patterns of identical documentation across unrelated patients.
Legal framework and obligations
Understand the False Claims Act and its qui tam provisions, the Anti-Kickback Statute, the Physician Self-Referral (Stark) Law, and the Civil Monetary Penalties Law. Know that the Affordable Care Act amended intent standards for the Anti-Kickback Statute and created the 60-day overpayment rule. Understand the role of the OIG, the meaning of an excluded individual, and the elements of a compliance program: written policies, a compliance officer, training, monitoring and auditing, and enforcement and correction.
Traps to watch
Questions often conflate the Anti-Kickback Statute (any federal health program, remuneration for referrals) with Stark (physician self-referral for designated health services, strict liability). Another trap is treating an overpayment as fraud regardless of intent.
Rule of thumb
When a pattern emerges, ask: is this an error, a misuse, or intentional deception? That classification drives the response-education and correction, voluntary refund, or referral for investigation.