MEDICARE FRAUD AND ABUSE

As the CMS Part B Contractor for Maine, Massachusetts, New Hampshire, and Vermont, NHIC
fully supports the CMS initiative for program safeguards and shares the following information
for your use:

Fraud is the intentional deception or misrepresentation that the 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 line 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. Attempts to defraud the Medicare
program may take a variety of forms. Some examples include:
• Billing for services or supplies that were not provided;
• Misrepresenting services rendered or the diagnosis for the patient to justify the services or
equipment furnished;
• Altering a claim form to obtain a higher amount paid;
• Soliciting, offering, or receiving a kickback, bribe, or rebate;
• Completing Certificates of Medical Necessity (CMNs) for patients not personally and
professionally known by the provider; and
• Use of another person’s Medicare card to obtain medical care.

Abuse describes incidents or practices of providers that are inconsistent with accepted sound
medical practices, directly or indirectly resulting in unnecessary costs to the program, improper
payment for services that fail to meet professionally recognized standards of care, or services that
are medically unnecessary. Abuse takes such forms as, but is not limited to:

• Unbundled charges;
• Excessive charges;
• Medically unnecessary services; and
• Improper billing practices.

Although these practices may initially be considered as abuse, under certain circumstances they
may be considered fraudulent. Any allegations of potential fraud or abuse should be referred to
the Benefits Integrity Safeguard Contractor.