What is CMS fraud, waste, and abuse?

The Centers for Medicare and Medicaid Services (CMS) is an agency within the US Department of Health and Human Services. CMS administers the Medicare and Medicare Programs, as well as several other health-related government programs. In addition to overseeing these programs, CMS helps to ensure that requests for benefits are legitimate and made in accordance with rules, regulations, and federal law.

Unethical doctors and other healthcare workers will try to exploit Medicare and Medicaid to received additional money beyond what they are rightfully (and legally) owed. Such actions fall into one of three categories: fraud, waste, and abuse. Not included are inadvertent mistakes––which can happen on occasion––as long as the mistakes are isolated and not an ongoing issue.

Fraud, waste, and abuse can all be serious issues, can all cost US taxpayers billions of dollars, and can all result in civil and/or criminal penalties. Because they are all shades of the same unethical behavior, it can be difficult to distinguish one from another. The Office of the Inspector General of the Department of Health and Human Services uses the following definitions:

Fraud:

• Nature: Deliberate and intentional deception.

• Illegal Aspect: Involves actions that are verifiably illegal.

• Intent: The person committing fraud has the intention to deceive and gain financially.

• Examples: Billing for services not provided, falsifying patient records, identity theft, kickbacks, or bribery.

Waste:

• Nature: Inefficiencies that lead to unnecessary costs.

• Unethical Intent: May or may not involve unethical intent; can be deliberate or unintentional.

• Examples: Ordering excessive lab tests, unnecessary medical procedures, or overprescribing medications, without necessarily intending to deceive.

Abuse:

• Nature: Actions that go against accepted healthcare practices and may result in unnecessary costs.

• Rule-Bending: Involves bending the rules or overstepping acceptable boundaries.

• Examples: Overcharging for services or supplies, not coding procedures correctly to inflate billing, and generally taking advantage of loopholes without the explicit intention to deceive.

It's crucial to differentiate these categories as they have different implications and consequences. Proper monitoring and enforcement are essential to prevent financial losses and maintain the integrity of healthcare programs. Detecting and addressing fraud, waste, and abuse contribute to the sustainability of these programs and ensure that they fulfill their intended purpose of providing quality healthcare services to eligible individuals. Additionally, efforts to educate healthcare providers and the public about the distinctions and consequences of these behaviors play a vital role in preventing and combating such activities.