What is Fraud & Abuse?
DEFINITION OF FRAUD
An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State Law.
DEFINITION OF ABUSE
Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid/TennCare/Cover TN Program.
TYPES OF FRAUD AND ABUSE
Examples of cases that the Office of Inspector General investigates include unreported income or insurance, TennCare/Cover TN recipients living out of state, drug seeking behavior, incarceration, individuals receiving bills (or EOB statements) for services never provided, provider billing irregularities, over or under utilization of health care services, and misrepresentation of credentials. Provider fraud involves not only doctors, but nursing homes, home health, durable medical equipment, pharmacies, mental health facilities, laboratories, transportation and dentists, to name a few.
WHAT IS IN IT FOR YOU?
The Office of Inspector General along with the Tennessee Bureau of Investigation, Medicaid Fraud Control Unit, Federal Bureau of Investigation, Attorney General's Office, Department of Human Services, and many other departmental offices have recovered millions of public health dollars. We provide our expertise, consultation and staff to all departments to help combat fraud, abuse, and waste within the Tennessee Health Care Programs.