Module 1, Topic 1
In Progress

Day 3: Fraud & Abuse

Petria September 3, 2020


Medicare fraud typically includes any of the following:

  • Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist
  • Knowingly soliciting, receiving, offering, and/or paying remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs
  • Making prohibited referrals for certain designated health services


  • Medicare fraud and abuse examples
  • Overview of the laws used to fight fraud and abuse
  • Descriptions of the partnerships among government agencies dedicated to preventing, detecting, and fighting fraud and abuse
  • Resources on how to report suspected fraud and abuse

Examples of Medicare abuse include: ​

  • Billing for unnecessary medical services ​
  • Charging excessively for services or supplies ​
  • Misusing codes on a claim, such as upcoding or unbundling codes​

Program integrity encompasses a range of activities targeting various causes of improper payments.

What I am noticing is how the fines and penalties are becoming larger and larger each year.


Federal laws governing Medicare fraud and abuse include all of the following:

  • False Claims Act (FCA)
  • Anti-Kickback Statute (AKS)
  • Physician Self-Referral Law (Stark Law)
  • Social Security Act
  • United States Criminal Code

Office of Inspector General (OIG)

The OIG protects the integrity of HHS’ programs, including Medicare, and the health and welfare of its beneficiaries. The OIG operates through a nationwide network of audits, investigations, inspections, and other related functions. The Inspector General is authorized to, among other things, exclude individuals and entities who engage in fraud or abuse from participation in Medicare, Medicaid, and other Federal health care programs, and to impose CMPs for certain violations related to Federal health care programs.

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

Beginning in 2009, HEAT was created as a joint effort between the Department of Health and Human Services and the Department of Justice – agencies responsible for the investigation and prosecution of healthcare fraud.

The DOJ, OIG, and HHS established HEAT to build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent fraud and abuse. HEAT expanded the DOJ-HHS Medicare Fraud Strike Force, which targets emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers. Training website.


CMS Contractors by State

Review Contractor Directory – Interactive Map
The Review Contractor Directory – Interactive Map allows you to access state-specific CMS contractor contact information. You may receive correspondence from one or several of these contractors in your state. They may request medical records from you, as they perform business on behalf of CMS. You can use this website to access their contact information including emails, phone numbers and websites.  Interactive Map