Fraud: Intentional Deceit
- Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist;
- Knowingly soliciting, paying, and/or accepting remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs; or
- Making prohibited referrals for certain designated health services
Waste: Inefficient Practices
- Waste, according to Centers for Medicare and Medicaid Services (CMS), is the result of honest mistakes and human errors.
- Waste implies no malicious intent. But, as the term suggests, spending is inefficient and costly.
Abuse: Bending the Rules
- Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicaid Program.
- Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and priced fairly.