How Does Medicare Define "Fraud" and "Abuse
Medicare defines fraud as "The intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception 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 misrepresentation made, or caused to be made, that is material to entitlement or payment under the Medicare program. The violator may be a physician or other practitioner, a supplier of durable medical equipment, and employee of a physician or supplier, a carrier employee, a billing service, a beneficiary, or any other person or business entity in a position to bill the Medicare program or to otherwise benefit from such billing. Abuse is defined as "Incidents or practices of physicians or suppliers of equipment which, although not usually considered fraudulent, are inconsistent with accepted sound medical, business or fiscal practices".

It is the providers' responsibility to stay current with Medicare rules and regulations and to ensure administrative personnel understand Medicare guidelines as they pertain to coding and billing of services provided. 

The carrier's (WPS) Fraud and Abuse Unit's primary role is to identify cases of suspected fraud and abuse, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped. Where appropriate, the carrier must refer cases to the Office of Inspector General for consideration and initiation of criminal, civil monetary penalty, and/or administrative sanction actions.