Fraud

The Centers for Medicare and Medicaid Services (CMS) defines fraud as an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person. The most frequent kind of fraud arises from a false statement or representation that is material to entitlement or payment under the Medicare/Medicaid program. The violator may be a practitioner, physician supplier, contractor employee, or beneficiary.

Examples of Fraud

include, but are not limited to the following

  • Billing for services or supplies that weren't provided
  • Altering claims to obtain higher payments
  • Soliciting, offering, or receiving a kickback, bribe, or rebate (example: paying for referral of clients)
  • Provider completing Certificates of Medical Necessity (CME) for patients not known to the provider
  • Suppliers completing CMEs for the physician
  • Using another person's Medicare card to obtain medical care

Abuse

CMS defines abuse as behaviors or practices of providers, physicians, or suppliers of services and equipment that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business, or fiscal practices. The practices may, directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or which are medically unnecessary.

Examples of Abuse

include, but are not limited to the following

  • Excessive charging for services or supplies
  • Claims for services that don't meet CMS medical necessity criteria
  • Breach of the Medicare/Medicaid participation or assignment agreements
  • Improper billing or coding practices.

In lay terms, fraud and abuse may also include

  • "Phantom Patients"
  • Enrolling deceased patients
  • Billing for services not performed
  • Double billing
  • Intentional improper billing
  • Unnecessary services
  • Kickbacks
  • Up coding
  • Unbundling
  • Falsification of health care provider credentials
  • Falsification of provider financial solvency
  • Related party contracting
  • Incentives that limit services or referral
  • Embezzlement and theft
  • Billing Medicaid enrollees for BHO covered services.

Report suspected Medicaid fraud and abuse to our Compliance Officer

By Phone

P: 360.416.7013 x617 | 800.684.3555 x617

Fax

F: 360.416.7017

Email

compliance_officer@northsoundbho.org

By Mail

301 Valley Mall Way, Suite 110
Mount Vernon, WA 98273

You may also anonymously report suspected Medicaid fraud and abuse through the following contacts

Medicaid Fraud Control Office of the Attorney General Medicaid Fraud Control Unit

P: 253.593.2154
P: 253.593.2155
F: 253.593.5135

OIG National Fraud Hotline


T: 800.447.8477

Regional Fraud & Abuse Coordinator

Liz Trias, CMH, DMCH

2201 6th Ave. M/S 43
Seattle, WA 98121
P: 206.615.2400
F: 206.615.3804
E: etrias@cms.hhs.gov

Or

Regional Fraud & Abuse Coordinator

Sharon Last, CMS, DMCH

2201 6th Ave. M/S 43
Seattle, WA 98121
P: 206.615.2383
F: 206.615.3804
E: slast@cms.hhs.gov