Fraud, Waste, and Abuse Detection and Case Referral
Provisional domain 3: Fraud, Waste, and Abuse Detection and Case Referral. This provisional section tests whether you can distinguish intent, triage an anomaly, preserve evidence, and route a case without overstepping authority.
Core rules
- Fraud involves intentional deception or misrepresentation. Waste is avoidable cost without intent. Abuse is improper practice inconsistent with sound standards but not necessarily intentional.
- Common indicators include statistical outliers, unbundling, duplicate billing, impossible volume, beneficiary sharing, rapid enrollment-to-payment cycles, and services inconsistent with the diagnosis.
- Triage by credibility, materiality, urgency, and jurisdiction. A single coding error is not automatically fraud; a pattern of unsupported high-value claims may be.
- Preserve original records, audit logs, and chain of custody. Do not alter records, confront the subject, or tip off the subject. Refer to the designated investigative unit.
Worked example
A provider bills 18 hours of one-on-one counseling in a 24-hour day for 10 consecutive days. This is an impossible-volume indicator. First verify time records and service documentation; if unsupported, treat it as a potential fraud referral, not a final fraud finding. Reasoning: intake identifies indicators and preserves evidence; intent is decided later by the authorized investigator or adjudicator. Refer with the claim data, dates, and documents.
Traps
Labeling every error fraud; investigating outside your authority; altering or deleting records; contacting the subject before referral; and dismissing small but patterned waste because each item is below a threshold.