when waste becomes fraud: the grey area

Unlike waste and even abuse, which are characterized by an unintentional practice that directly or indirectly results in an overpayment, fraudsters are distinguished by their intention to obtain monies that they are not otherwise entitled to receive. The challenge that health plans face is that within the spectrum of fraud, waste, and abuse (FWA), it is often unclear if a billing mistake is accidental or unintentional.

Take a closer look at five of the most common billing patterns that we’ve identified as potential fraud schemes in our latest report, “when waste becomes fraud: the grey area.” In this report, we discuss:

  • When service volume should be flagged as potential fraudulent activity
  • How providers may leverage excessive testing as a billing scheme
  • Why unbundling procedure codes should signal further investigation

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