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1. Question: What is the difference between fraud and abuse?

Answer: Fraud is the intentional deception or misrepresentation of facts that an individual or an organization perpetrates for the purpose of gaining an otherwise unauthorized or illegitimate benefit for himself/herself, some other person, or an organization. Abuse involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. The real difference between fraud and abuse is the person's intent. Both have the same impact: they detract valuable resources from the Medicare Trust Fund that would otherwise be used to provide care to Medicare beneficiaries.

2. Question: What are some common situations that should be referred to fraud?

Answer: The acceptance or offering of “Kickbacks”. Routine waiver of co-payments, falsifying certificates of medical necessity, plans of care and other records, billing for services not rendered, misrepresenting the diagnosis to justify payment, and beneficiaries sharing Medicare cards are just some of the more common schemes.

3. Question: How do I know if there is suspected fraud and how would I report it?

Answer: Review your Medicare Summary Notice when you receive it, and make sure you understand all of the items listed. If you don’t remember a procedure that is listed, you should first call your physician, provider, or supplier that is listed on the Medicare Summary Notice. Many times a simple mistake has been made and can be corrected by your physician, provider, or supplier’s office when you call. If your physician, provider, or supplier’s office does not help you with the questions or concerns about items listed on your Medicare Summary Notice and you still suspect Medicare fraud or if you cannot call them, you should call or write the Medicare company that paid the claim. The name, address, and telephone number are on the Medicare Summary Notice (MSN) you receive, which shows what Medicare paid.

Before contacting the Medicare claims processing company, carefully review the facts as you know them and as shown on the Medicare Summary Notice. Write down:
• The provider's name and any identifying number you may have.
• The item or service you are questioning.
• The date on which the item or service was supposedly furnished.
• The amount approved and paid by Medicare.
• The date of the Medicare Summary Notice.
• The name and Medicare number of the person who supposedly received the item or service.
• The reason you believe Medicare should not have paid.

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