Defining Fraud and Abuse
Healthcare fraud involves knowingly submitting false claims or making false statements to obtain payment for services, while abuse involves practices that are inconsistent with accepted medical or business practices and result in unnecessary costs, without the same element of intentional deception. RHIA candidates must be able to distinguish these concepts, since the required intent differs significantly.
Common Examples of Fraud
- Billing for services never rendered
- Upcoding to a higher-paying code than the documentation supports
- Falsifying medical records to justify unnecessary services
- Billing for a higher level of care than actually provided
Common Examples of Abuse
- Billing errors resulting from misunderstanding coding rules
- Ordering excessive tests without fraudulent intent
- Charging excessively for services or supplies
Key Federal Laws
The False Claims Act imposes civil liability on anyone who knowingly submits a false claim to the federal government and allows whistleblowers to file qui tam lawsuits on the government's behalf. The Health Insurance Portability and Accountability Act also created criminal penalties for healthcare fraud, expanding enforcement tools beyond the False Claims Act.
Enforcement Agencies
The Office of Inspector General for the Department of Health and Human Services conducts audits and investigations, publishes an annual work plan identifying compliance risk areas, and can exclude individuals or entities from federal healthcare programs. The Department of Justice prosecutes criminal fraud cases and pursues civil False Claims Act litigation.
HIM's Role in Fraud Prevention
Health information professionals support fraud prevention through accurate coding practices, participation in compliance audits, and ensuring documentation genuinely supports billed services. Coding compliance plans, regular internal audits, and staff education are core components of an effective fraud prevention program.
Reporting Obligations
Employees who suspect fraud typically have an obligation to report concerns through internal compliance hotlines, and organizations must protect whistleblowers from retaliation under various federal and state protections.
Exam Tips
Expect scenario questions requiring you to classify a situation as fraud or abuse based on the presence or absence of intent, and to identify the appropriate law or agency associated with a given enforcement scenario.