What is Provider Abuse and Fraud?


  Abuse means provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary, upcoded, or that fail to meet professionally recognized standards for health care. Abuse includes recipient practices that result in unnecessary cost to the Medicaid program. Abuse may also include a
violation of state or federal law, rule or regulation.


Overpayment includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claims, unacceptable practices, fraud, abuse or mistake.


Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception results in unauthorized benefit to herself or himself or another person. The term includes any act that

constitutes fraud under applicable federal or state law.

AHCA may require repayment for inappropriate, medically unnecessary, or excessive goods or services from the person furnishing them, the person under whose supervision they were furnished, or the person causing them to be furnished.

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