Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

CMS Regulation Guide

(Centers for Medicare & Medicaid Services)
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

MEDICARE FRAUD & ABUSE:

PREVENTION, DETECTION, AND REPORTING
ICN 006827 October 2016

Table of Contents
Medicare Fraud and Abuse: A Serious Problem That Needs Your Attention............ 2
What Is Medicare Fraud? ............................................................................................... 2
What Is Medicare Abuse? .............................................................................................. 3
Medicare Fraud and Abuse Laws .................................................................................. 4
Federal False Claims Act (FCA) .................................................................................... 4
Anti-Kickback Statute (AKS) .......................................................................................... 5
Physician Self-Referral Law (Stark Law) ....................................................................... 5
Criminal Health Care Fraud Statute............................................................................... 5
Additional Medicare Fraud and Abuse Penalties ........................................................... 6
Exclusions...................................................................................................................... 6
Civil Monetary Penalties Law......................................................................................... 7
Medicare Fraud and Abuse Partnerships ..................................................................... 8
Public-Private Health Care Fraud Prevention Partnership ............................................ 8
Centers for Medicare & Medicaid Services (CMS) ........................................................ 8
Office of Inspector General (OIG) ................................................................................ 10
Health Care Fraud Prevention and Enforcement Action Team (HEAT) ....................... 10
General Services Administration (GSA)....................................................................... 10
Report Suspected Fraud .............................................................................................. 11
Resources ..................................................................................................................... 12

Please note: The information in this publication applies to the Medicare Fee-For-Service
Program (also known as Original Medicare). Many of the laws discussed apply to all
Federal Health Care Programs (including Medicaid and Medicare Managed Care).
Table 5. Hyperlink Table, at the end of this document, provides the complete URL
for each hyperlink.
1
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

You Can Help Fight Fraud — Report It!

The Office of Inspector General (OIG) Hotline accepts tips and complaints from all
sources on potential fraud, waste, and abuse. View instructional videos about the
OIG Hotline operations, as well as reporting fraud to the OIG.

Medicare Fraud and Abuse: A Serious Problem That

Needs Your Attention
Although no precise measure of health care fraud exists, those intent on abusing Federal
health care programs can cost taxpayers billions of dollars while putting beneficiaries’
health and welfare at risk. Medicare fraud and abuse increases the financial strain on
the Medicare Trust Fund. The impact of these losses and risks magnifies as Medicare
continues to serve a growing number of people.
You play a vital role in protecting the integrity of the Medicare Program. To combat
fraud and abuse, you need to know how to protect your organization from engaging in
abusive practices and civil or criminal activity. This publication provides the following
tools to help protect the Medicare Program, your patients, and yourself:
● 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

What Is Medicare Fraud?

Medicare fraud typically includes any of the following:
Case Studies
● Knowingly submitting, or causing to be submitted,
To learn about real-life
false claims or making misrepresentations of cases of Medicare fraud
fact to obtain a Federal health care payment for and abuse and the
which no entitlement would otherwise exist consequences for culprits,
● Knowingly soliciting, receiving, offering, and/or visit the Stop Medicare
paying remuneration to induce or reward referrals Fraud Newsroom.
for items or services reimbursed by Federal
health care programs
● Making prohibited referrals for certain designated health services

Anyone can commit health care fraud. Fraud schemes range from solo ventures to
broad-based operations by an institution or group. Even organized crime has infiltrated
the Medicare Program and masqueraded as Medicare providers and suppliers.
Examples of Medicare fraud include:
● Billing Medicare for appointments the patient failed to keep
2
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

● Knowingly billing for services at a level of complexity higher than services actually
provided or documented in the file
● Knowingly billing for services not furnished, supplies not provided, or both, including
falsifying records to show delivery of such items
● Paying for referrals of Federal health care program beneficiaries

Defrauding the Federal Government and its programs is illegal. Committing Medicare
fraud exposes individuals or entities to potential criminal and civil liability, and may lead
to imprisonment, fines, and penalties. Criminal and civil penalties for Medicare fraud
reflect the serious harms associated with health care fraud and the need for aggressive
and appropriate intervention. Providers and health care organizations involved in health
care fraud risk exclusion from participating in all Federal health care programs and risk
losing their professional licenses.

What Is Medicare Abuse?

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to
the Medicare Program. Abuse includes any practice not consistent with providing patients
with services that are medically necessary, meet professionally recognized standards,
and are priced fairly.
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

Medicare abuse can also expose providers to criminal and civil liability.
Program integrity encompasses a range of activities targeting various causes of
improper payments. The following shows examples along the spectrum of causes of
improper payments.*
● Mistakes Result in Errors: Such as Incorrect Coding
● Inefficiencies Result in Waste: Such as Ordering Excessive Diagnostic Tests
● Bending the Rules Results in Abuse: Such as Improper Billing Practices
(Like Upcoding)
● Intentional Deceptions Result in Fraud: Such as Billing for Services or Supplies
That Were Not Provided
* The types of improper payments above are examples for educational purposes.
Providers who engage incorrect coding, ordering excessive diagnostic tests, upcoding,
or billing for services or supplies not provided may be subject to administrative, civil,
or criminal liability.

3
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Medicare Fraud and Abuse Laws

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

These laws specify the criminal, civil, and administrative remedies the government may
impose on individuals or entities that commit fraud and abuse in the Medicare Program,
including Medicare Parts C and D and the Medicaid Program. Violating these laws may
result in nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from all
Federal health care programs, and criminal and civil liability. We briefly summarize
each law below, and you can find hyperlinks to the text of the laws at the end of this
section in Table 1.

CMP Inflation Adjustment

In 2016, the Federal Government adjusted all CMPs for inflation. These adjusted
amounts apply to civil penalties assessed after August 1, 2016, whose associated
violations occurred after November 2, 2015. Future inflation adjustments will occur
annually, at the beginning of each calendar year.

Federal False Claims Act (FCA)

The FCA protects the Federal Government from being overcharged or sold substandard
goods or services. The FCA imposes civil liability on any person who knowingly submits,
or causes the submission of, a false or fraudulent claim to the Federal Government.
The terms “knowing” and “knowingly” mean a person has actual knowledge of the
information or acts in deliberate ignorance or reckless disregard of the truth or falsity of
the information related to the claim. No proof of specific intent to defraud is required to
violate the civil FCA.
Example: A physician knowingly submits claims to Medicare for a higher level of
medical services than actually provided or higher than the medical record documents.
Penalties: Civil penalties for violating the FCA may include fines of up to three
times the amount of damages sustained by the Government as a result of the false
claims plus up to $21,563 (in 2016) per false claim filed.
There also is a criminal FCA statute by which individuals or entities that submit false
claims may face fines, imprisonment, or both.

4
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Anti-Kickback Statute (AKS)

The AKS makes it a crime to knowingly and willfully
offer, pay, solicit, or receive any remuneration directly Anti-Kickback Statute vs.
or indirectly to induce or reward referrals of items or Stark Law
services reimbursable by a Federal health care program. Refer to the Comparison of
the Anti-Kickback Statute
Example: A provider receives cash or below and Stark Law handout.
fair market value rent for medical office space
in exchange for referrals.
Penalties: Civil penalties for violating the AKS may include penalties of up to
$73,588 (in 2016) per kickback plus three times the amount of the kickback.
Criminal penalties for violating the AKS may include fines, imprisonment, or both.
If certain types of arrangements satisfy regulatory safe harbors, they may not violate
the AKS.

Physician Self-Referral Law (Stark Law)

The Physician Self-Referral Law, often called the Stark
Law, prohibits a physician from making a referral for What Is an Entity?
certain designated health services payable by Medicare Refer to the Code of
or Medicaid to an entity in which the physician (or an Federal Regulations (CFR)
immediate family member) has an ownership/investment for more information about
interest or with which he or she has a compensation the definition of an entity.
arrangement, unless an exception applies.
Example: A provider refers a beneficiary for a designated health service to a
business in which the provider has an investment interest.
Penalties: Penalties for physicians who violate the Stark Law may include fines,
CMPs up to $23,863 (in 2016) for each service, repayment of claims, and potential
exclusion from all Federal health care programs.

Criminal Health Care Fraud Statute

The Criminal Health Care Fraud Statute prohibits knowingly and willfully executing, or
attempting to execute, a scheme or artifice in connection with the delivery of or payment
for health care benefits, items, or services to either:
● Defraud any health care benefit program
● Obtain (by means of false or fraudulent pretenses, representations, or promises)
any of the money or property owned by, or under the control of, any health care
benefit program
Example: Several doctors and medical clinics conspire in a coordinated scheme
to defraud the Medicare Program by submitting claims for power wheelchairs that
were not medically necessary.
Penalties: Penalties for violating the Criminal Health Care Fraud Statute may
include fines, imprisonment, or both.
5
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

COMPARISON OF THE ANTI-KICKBACK STATUTE AND STARK LAW*

THE ANTI-KICKBACK THE STARK LAW

STATUTE (42 USC § 1395nn)
(42 USC § 1320a-7b(b))
Prohibition Prohibits offering, paying, Prohibits a physician from referring Medicare patients
soliciting or receiving anything of for designated health services to an entity with which
value to induce or reward referrals the physician (or immediate family member) has a
or generate Federal health care financial relationship, unless an exception applies
program business Prohibits the designated health services entity from
submitting claims to Medicare for those services
resulting from a prohibited referral
Referrals Referrals from anyone Referrals from a physician
Items/ Any items or services Designated health services
Services
Intent Intent must be proven (knowing No intent standard for overpayment (strict liability)
and willful) Intent required for civil monetary penalties for
knowing violations
Penalties Criminal: Civil:
Fines up to $25,000 per Overpayment/refund obligation
violation False Claims Act liability
Up to a 5 year prison term Civil monetary penalties and program exclusion for
per violation knowing violations
Civil/Administrative: Potential $15,000 CMP for each service
False Claims Act liability
Civil assessment of up to three times the amount
Civil monetary penalties
claimed
and program exclusion
Potential $50,000 CMP per
violation
Civil assessment of up to
three times amount of
kickback
Exceptions Voluntary safe harbors Mandatory exceptions
Federal All Medicare/Medicaid
Health Care
Programs
*This chart is for illustrative purposes only and is not a substitute for consulting the statutes and their
regulations.
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Additional Medicare Fraud and Abuse Penalties

Aside from the civil and criminal actions brought by law enforcement agencies, the
Medicare Program has additional administrative remedies applicable for certain fraud
and abuse violations.

Exclusions
Under the Exclusion Statute, the OIG must exclude from participation in all Federal
health care programs any providers and suppliers convicted of any of the following:
● Medicare fraud, as well as any other offenses related to the delivery of items or
services under Medicare
● Patient abuse or neglect
● Felony convictions for other health care-related fraud, theft, or other
financial misconduct
● Felony convictions for unlawful manufacture, distribution, prescription, or dispensing
of controlled substances
OIG also has discretion to impose permissive exclusions on other grounds, including:
● Misdemeanor convictions related to health care fraud other than Medicare or
Medicaid fraud, or misdemeanor convictions in connection with the unlawful
manufacture, distribution, prescription, or dispensing of controlled substances
● Suspension, revocation, or surrender of a license to provide health care for
reasons bearing on professional competence, professional performance, or
financial integrity
● Provision of unnecessary or substandard services; submission of false or fraudulent
claims to a Federal health care program
● Engaging in unlawful kickback arrangements
● Defaulting on health education loan or scholarship obligations

Excluded providers may not participate in Federal health care programs for a designated
period. An excluded provider may not bill Federal health care programs (including, but
not limited to, Medicare, Medicaid, and State Children’s Health Insurance Program
[SCHIP]) for services he or she orders or performs. Additionally, an employer or a group
practice may not bill for an excluded provider’s services. At the end of an exclusion period,
an excluded provider must seek reinstatement; reinstatement is not automatic. The OIG
maintains a list of excluded parties called the List of Excluded Individuals/Entities (LEIE).

6
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Civil Monetary Penalties Law

The Civil Monetary Penalties Law authorizes the imposition of CMPs for a variety of health
care fraud violations. Different amounts of penalties and assessments may be authorized
based on the type of violation. Penalties range from $21,563 to $73,568 (in 2016) per
violation. CMPs also may include an assessment of up to three times the amount claimed
for each item or service, or up to three times the amount of remuneration offered, paid,
solicited, or received. Violations that may justify CMPs include:
● Presenting a claim you know, or should know, is for an item or service not provided
as claimed or that is false and fraudulent
● Presenting a claim you know, or should know, is for an item or service for which
Medicare will not pay
● Violating the AKS

Table 1. Table of Statutes

Statute Reference
Civil FCA https://www.gpo.gov/fdsys/pkg/USCODE-
31 United States Code (U.S.C.) 2015-title31/pdf/USCODE-2015-title31-
Sections 3729-3733 subtitleIII-chap37-subchapIII.pdf
Civil Monetary Penalties
Inflation Adjustment
https://www.gpo.gov/fdsys/pkg/FR-2016-
06-30/pdf/2016-15528.pdf
Criminal FCA https://www.gpo.gov/fdsys/pkg/USCODE-
18 U.S.C. Section 287 2015-title18/pdf/USCODE-2015-title18-
partI-chap15-sec287.pdf
AKS https://www.gpo.gov/fdsys/pkg/USCODE-
42 U.S.C. 1320a-7b(b) 2015-title42/pdf/USCODE-2015-title42-
chap7-subchapXI-partA-sec1320a-7b.pdf
Regulatory Safe Harbors https://www.gpo.gov/fdsys/pkg/CFR-2015-
42 Code of Federal Regulations (CFR) title42-vol5/pdf/CFR-2015-title42-vol5-
Section 1001.952 sec1001-952.pdf
Physician Self-Referral Law https://www.gpo.gov/fdsys/pkg/USCODE-
42 U.S.C. Section 1395nn 2015-title42/pdf/USCODE-2015-title42-
chap7-subchapXVIII-partE-sec1395nn.pdf
Criminal Health Care Fraud https://www.gpo.gov/fdsys/pkg/USCODE-
18 U.S.C. Section 1347 2015-title18/pdf/USCODE-2015-title18-
partI-chap63-sec1347.pdf

7
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Table 1. Table of Statutes (cont.)

Statute Reference
Exclusion https://www.gpo.gov/fdsys/pkg/USCODE-
42 U.S.C. Section 1320a-7 2015-title42/pdf/USCODE-2015-title42-
chap7-subchapXI-partA-sec1320a-7.pdf
Civil Monetary Penalties Law https://www.gpo.gov/fdsys/pkg/USCODE-
42 U.S.C. Section 1320a-7a 2015-title42/pdf/USCODE-2015-title42-
chap7-subchapXI-partA-sec1320a-7a.pdf
Adjustment of Civil Monetary Penalties
for Inflation
https://www.gpo.gov/fdsys/pkg/FR-2016-
09-06/pdf/2016-18680.pdf

Medicare Fraud and Abuse Partnerships

Government agencies partner to fight fraud and abuse, uphold the Medicare Program’s
integrity, save and recoup taxpayer funds, reduce health care costs, and improve the
quality of care.

Public-Private Health Care Fraud Prevention Partnership

The Public-Private Partnership to Prevent Health Care Fraud (Partnership) is a
public-private forum for the Federal Government and private and State organizations,
including insurers, to prevent health care fraud on a national scale. Public and private
sector partners exchange information and best practices to detect and prevent fraudulent
claims and payments. The Partnership also analyzes industry-wide data to help detect
and predict fraud schemes.

Centers for Medicare & Medicaid Services (CMS)

CMS is the Federal agency within the U.S. Department of Health and Human Services
(HHS) that administers the Medicare, Medicaid, SCHIP, Health Insurance Portability and
Accountability Act of 1996 (HIPAA), Clinical Laboratory Improvement Amendments (CLIA),
and several other health-related programs.
To prevent and detect fraud and abuse, CMS works with individuals, entities, and law
enforcement agencies, including:
● Accreditation Organizations (AOs)
● Medicare beneficiaries and caregivers
● Physicians, suppliers, and other health care providers
● State and Federal law enforcement agencies, including the OIG, Federal Bureau
of Investigation (FBI), Department of Justice (DOJ), State Medicaid Agencies, and
Medicaid Fraud Control Units (MFCUs)
8
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

To support its efforts to prevent, detect, and investigate potential Medicare fraud and
abuse, CMS also contracts with an array of contractors listed in Table 2.
Table 2. Contractors Who Support Efforts to Prevent, Detect, and Investigate Fraud
and Abuse

Contractor Role
Comprehensive Error Rate Testing Help calculate the Medicare
(CERT) Contractors Fee-For-Service (FFS) improper payment
rate by reviewing claims to determine if
they were paid properly
Medicare Administrative Process claims and enroll providers
Contractors (MACs) and suppliers
Medicare Drug Integrity Monitor fraud, waste, and abuse in the
Contractors (MEDICs) Medicare Parts C and D Programs
Recovery Audit Program Reduce improper payments by detecting
Recovery Auditors and collecting overpayments and
identifying underpayments
Zone Program Integrity Investigate potential fraud, waste, and
Contractors (ZPICs) abuse for Medicare Parts A and B;
Formerly called Program Safeguard Durable Medical Equipment Prosthetics,
Contractors (PSCs) Orthotics, and Supplies; and Home Health
and Hospice
Unified Program Integrity Will operate under restructured/consolidated
Contractor (UPIC) Medicare and Medicaid Program Integrity
audit and investigation work
(Not yet implemented)

Within CMS, the Center for Program Integrity (CPI) promotes the integrity of Medicare
through audits, policy reviews, and identifying and monitoring program vulnerabilities.
CPI oversees CMS’ collaborative interactions with key stakeholders on program integrity
issues related to the detecting, deterring, monitoring, and combating fraud and abuse.
Visit the CMS Blog for the latest CPI news.
In 2010, HHS and CMS launched an ambitious national effort to obstruct criminals at
every step in the act of committing fraud. The Fraud Prevention System (FPS) is the
state-of-the-art predictive analytics technology that runs predictive algorithms and other
analytics nationwide on all Medicare FFS claims prior to payment. For the first time in
Medicare history, CMS systematically applies advanced analytics to the Medicare FFS
claims on a streaming, nationwide basis.

9
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

In 2012, CMS created the Program Integrity Command Center to bring together Medicare
and Medicaid officials, clinicians, policy experts, CMS fraud investigators, and the law
enforcement community, including the OIG and FBI. The Command Center gathers
these experts to develop and improve intricate predictive analytics that identify fraud and
mobilize a rapid fraud response. CMS uses this technology to connect instantly with its
field offices and evaluate fraud allegations through real-time investigations. Previously,
finding substantiating evidence of a fraud allegation took days or weeks; now it takes
mere hours.

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 carries out its duties through a nationwide network
of audits, investigations, inspections, and other related functions. The Inspector General
has the authority to 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)
The DOJ 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 efforts included expanding the DOJ-HHS Medicare Fraud Strike
Force, which successfully fights fraud. HEAT created the Stop Medicare Fraud website,
which provides information about how to identify and protect against Medicare fraud and
how to report it.

General Services Administration (GSA)

The GSA consolidated several Federal procurement systems into one new system—
the System for Award Management (SAM). SAM incorporated the formerly maintained
Excluded Parties List System (EPLS). SAM includes information on entities that are:
● Debarred or proposed for debarment
● Disqualified from certain types of Federal financial and non-financial assistance
and benefits
● Disqualified from receiving Federal contracts or certain subcontracts
● Excluded
● Suspended

10
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Report Suspected Fraud

The following table tells you how to report Medicare fraud.
Table 3. Where Should You Report Fraud and Abuse?

If You Are a… Report Fraud to…

Medicare For any complaint:
Beneficiary ● CMS Hotline:
Phone: 1-800-MEDICARE (1-800-633-4227) or
TTY 1-877-486-2048 AND
● OIG Hotline:
Phone: 1-800-HHS-TIPS (1-800-447-8477) or
TTY 1-800-377-4950
Fax: 1-800-223-8164
Online: Forms.oig.hhs.gov/hotlineoperations
Mail: U.S. Department of Health & Human Services
Office of Inspector General
Attn: OIG Hotline Operations
P.O. Box 23489
Washington, DC 20026
For Medicare Part C (Managed Care) or Part D
(Prescription Drug Plans) complaints:
● 1-877-7SafeRx (1-877-772-3379)
Medicare ● OIG Hotline:
Provider Phone: 1-800-HHS-TIPS (1-800-447-8477) or
TTY 1-800-377-4950
Fax: 1-800-223-8164
Online: Forms.oig.hhs.gov/hotlineoperations
Mail: U.S. Department of Health & Human Services
Office of Inspector General
Attn: OIG Hotline Operations
P.O. Box 23489
Washington, DC 20026
OR
● Your local MAC

11
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Table 3. Where Should You Report Fraud and Abuse? (cont.)

If You Are a… Report Fraud to…

Medicaid ● OIG Hotline
Beneficiary Phone: 1-800-HHS-TIPS (1-800-447-8477) or
or Provider TTY 1-800-377-4950
Fax: 1-800-223-8164
Online: Forms.oig.hhs.gov/hotlineoperations
Mail: U.S. Department of Health & Human Services
Office of Inspector General
Attn: OIG Hotline Operations
P.O. Box 23489
Washington, DC 20026
OR
● Your Medicaid State Agency: State MFCUs are listed in the
State By State Fraud and Abuse Reporting Contacts

If you prefer to submit your complaint anonymously to the OIG Hotline, the OIG record
systems will contain no information that could trace the complaint to you. However, lack
of contact information may prevent OIG’s comprehensive review of the complaint, so the
OIG encourages you to provide contact information for possible follow-up.
Medicare and Medicaid beneficiaries can learn more about protecting themselves and
spotting fraud by contacting their local Senior Medicare Patrol (SMP) program.
For questions about Medicare billing procedures, billing errors, or questionable billing
practices, contact your MAC. For MAC contact information, including toll-free telephone
numbers, visit the Review Contractor Directory – Interactive Map.

Resources
For more information about the OIG and fraud, visit the OIG website. For more information
regarding preventing, detecting, and reporting fraud and abuse, as well as other Medicare
information, refer to the resources listed below in Table 4. Table 5 includes the complete
URL for all embedded hyperlinks in this booklet.
Table 4. Fraud and Abuse Resources

Resource Website
HHS http://www.hhs.gov
CMS https://www.cms.gov
HEAT Task Force https://www.stopmedicarefraud.gov/about
fraud/heattaskforce

12
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Table 4. Fraud and Abuse Resources (cont.)

Resource Website
OIG–Fraud https://oig.hhs.gov/fraud
CMS Fraud and Abuse Products https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/Fraud-
Abuse-Products.pdf
CMS Fraud Prevention Toolkit https://www.cms.gov/Outreach-and-
Education/Outreach/Partnerships/Fraud
PreventionToolkit.html
Frequently Asked Questions: Medicare https://questions.cms.gov/faq.php?id=
Fraud and Abuse 5005&rtopic=1887
“How CMS Is Fighting Fraud: Major https://www.medscape.org/viewarticle/
Program Integrity Initiatives” 764791
NOTE: To access this program, you need
to create a free account.
Medicaid Program Integrity Education https://www.cms.gov/medicare-medicaid-
coordination/fraud-prevention/medicaid-
integrity-education/edmic-landing.html
Medicaid Program Integrity: Safeguarding https://www.cms.gov/Outreach-and-
Your Medical Identity Products Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/SafeMed-
ID-Products.pdf
“Medicare Learning Network® Electronic https://www.cms.gov/Outreach-and-
Mailing Lists: Keeping Health Care Education/Medicare-Learning-Network-
Professionals Informed” fact sheet MLN/MLNProducts/MLN-Publications-
Items/CMS1243324.html
MLN Guided Pathways: Provider Specific https://www.cms.gov/Outreach-and-
Medicare Resources Education/Medicare-Learning-Network-
MLN/MLNEdWebGuide/Downloads/
Guided_Pathways_Provider_Specific_
booklet.pdf
MLN Provider Compliance https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/Provider
Compliance.html
OIG Advisory Opinions https://oig.hhs.gov/compliance/
advisory-opinions
OIG Compliance 101 https://oig.hhs.gov/compliance/101

13
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Table 4. Fraud and Abuse Resources (cont.)

Resource Website
OIG Email Updates https://oig.hhs.gov/contact-us
“Reducing Medicare and Medicaid Fraud https://www.medscape.org/viewarticle/
and Abuse: Protecting Practices 764496
and Patients” NOTE: To access this program, you need
to create a free account.
The “Basics of Medicare” Web-Based https://learner.mlnlms.com
Training (WBT) Series:
● Part One: History, program
overview, enrollment
● Part Two: Billing,
reimbursement, appeals
● Part Three: Claim review
programs, fraud and abuse,
outreach and education

Table 5. Hyperlink Table

Embedded Hyperlink Complete URL

CMS https://www.cms.gov
CMS Blog https://blog.cms.gov/category/cms-center-
for-program-integrity
Code of Federal Regulations https://www.gpo.gov/fdsys/pkg/CFR-2015-
title42-vol2/pdf/CFR-2015-title42-vol2-sec
411-351.pdf
Comparison of the Anti-Kickback Statute https://oig.hhs.gov/compliance/provider-
and Stark Law compliance-training/files/StarkandAKS
ChartHandout508.pdf
List of Excluded Individuals/Entities https://oig.hhs.gov/exclusions/exclusions_
list.asp
Local MAC https://www.cms.gov/Research-Statistics-
Data-and-Systems/Monitoring-Programs/
Medicare-FFS-Compliance-Programs/
Review-Contractor-Directory-
Interactive-Map
OIG Hotline Operations https://www.youtube.com/watch?v=
Wlsnd1DYG6Y

14
Docusign Envelope ID: 54B50523-6987-47C8-995C-DCE36233E720

Medicare Fraud & Abuse: Prevention, Detection, and Reporting

Table 5. Hyperlink Table (cont.)

Embedded Hyperlink Complete URL

OIG Website https://oig.hhs.gov
Physician Self-Referral Law https://www.cms.gov/Medicare/Fraud-and-
Abuse/PhysicianSelfReferral
Public-Private Partnership to Prevent https://www.stopmedicarefraud.gov/about
Health Care Fraud fraud/public-private
Regulatory Safe Harbors https://oig.hhs.gov/compliance/safe-
harbor-regulations
Reporting Fraud to the OIG https://www.youtube.com/watch?v=
nH7p30j7dOw
Review Contractor Directory – https://www.cms.gov/Research-Statistics-
Interactive Map Data-and-Systems/Monitoring-Programs/
Medicare-FFS-Compliance-Programs/
Review-Contractor-Directory-
Interactive-Map
Senior Medicare Patrol http://www.smpresource.org
State By State Fraud and Abuse https://www.cms.gov/Medicare-Medicaid-
Reporting Contacts Coordination/Fraud-Prevention/Fraud
AbuseforConsumers/Downloads/smafraud
contacts-oct2014.pdf
Stop Medicare Fraud https://www.stopmedicarefraud.gov
Stop Medicare Fraud Newsroom https://www.stopmedicarefraud.gov/
newsroom
System for Award Management https://www.sam.gov

This educational product was current at the time it was published or uploaded onto the web. Medicare
policy changes frequently so links to the source documents have been provided within the document for
your reference.

This educational product was prepared as a service to the public and is not intended to grant rights or
impose obligations. This educational product may contain references or links to statutes, regulations, or
other policy materials. The information provided is only intended to be a general summary. It is not intended
to take the place of either the written law or regulations. We encourage readers to review the specific
statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the
U.S. Department of Health & Human Services (HHS).

15