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Fraud, Waste, and Abuse

Understanding the terms:

Fraud: Intentional deception or misrepresentation to obtain the money or property of a health care benefit program (by means of false or fraudulent pretenses, representations, or promises).

  • Some examples of Fraud are: Knowingly billing for services not rendered, supplies not provided, or both, including falsifying records to show delivery of such items or billing for appointments that the patient did not attend.

Waste: The over-utilization of services or other practices that result in unnecessary costs.

  • Some examples of Waste are: Making excessive office visits or ordering excessive laboratory testing.

Abuse: Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments.

  • Some examples of Abuse are: Billing for services that were not medically necessary; charging excessively for services or supplies; and misusing codes on a claim, such as up-coding or unbundling services.

What can you do to help prevent, report, and stop Fraud, Waste, and Abuse?

To report potential fraud, waste and abuse in the Medicare program, please use one of the following applicable channels:

Medicare Fraud Hotline of the HHS office of Inspector General:

  • Phone: 1-800-447-8477 (TTY: 1-800-377-4950) Phone lines are open 24 hours a day, 7 days a week.
  • Fax: 1-800-223-8164
  • National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC): 1-877-7SafeRx (1-877-772-3379)