A health care organization takes the integrity of the care it provides and the programs it administers very seriously. If you are a provider or employee who works for such an organization and there is reason to believe that you may have committed health care abuse or fraud, the organization is likely to deal with you very strictly in the interest of preserving its own reputation.
Civil or criminal penalties can result from health care fraud or abuse if a court finds you culpable. Though the two terms are similar, they refer to different bad fiscal practices in a health care setting.
Health care abuse
In this context, the word “abuse” refers to business practices rather than harmful acts against a patient. Examples of health care abuse include billing for unnecessary medical services, misusing codes on a claim or charging excessively for supplies or services. According to Johns Hopkins Health Care, abuse includes not only business and fiscal practices but also medical practices that fail to meet professionally recognized standards and result in unnecessary cost or reimbursement.
Health care fraud
Health care fraud is a dishonest act committed deliberately to gain a benefit for you or someone else that neither you nor the other person would be able to enjoy otherwise. Examples include billing for services that are either not medically necessary, never performed or improperly documented. Health care fraud can also involve misrepresentation of the person rendering the service or the type or level of services provided. Additional examples include up-coding, which involves seeking increased payment for correctly coded services, and unbundling, or seeking separate payment for services that typically appear together on a bill.