Health care fraud and abuse
What is health care fraud and abuse?
- Fraud is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment or benefit. The attempt itself is fraud, regardless of whether it is successful.
- Waste is the expenditure, consumption, mismanagement, use of resources, practice of inefficient or ineffective procedures, systems, and/or controls to the detriment or potential detriment of entities. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Waste can be committed by a contractor, a subcontractor, a provider, and/or a FEHB beneficiary/enrollee.
- Abuse typically involves incidents or practices of providers that are inconsistent with accepted medical, business, or fiscal practices. These practices may, directly or indirectly, result in unnecessary costs, improper payments, or payments for services that fail to meet professionally recognized standards of care, or that are medically unnecessary.
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