ASSIGNMENT 3.2 CRITICAL THINKING: FRAUD VERSUS ABUSE Make a decision after reading each case study regarding whether it is considered fraud, abuse, or neither Performance Objective Task: Conditions: Use pen or pencil. Standards: Time: minutes Accuracy: (Note: The time element and accuracy criteria may be given by your instructor.) Directions: Read through each scenario and circle whether it is a fraud (F) issue, practice of abuse (A), or neither (N) To distinguish the difference between fraud and abuse situations, remember that under the Medicare program, abugs relates to incidents or practices that are inconsistent with accepted sound business practices, whereas fraud is intentions deception that an individual knows, or should know, to be false, and the individual knows the deception could result ; some unauthorized benefit to himself or herself or to some other person(s). Briefly explain the answer you selected Scenarios 1. Dr. Pedro Atrics has a friend whose child needs elective surgery. He agrees to perform the surgery and bill as an "insurance only" case. F A N Explain: 2. A patient, Carl Skinner, calls the office repeatedly about his prescriptions. When seen in the office the next time, Dr. Input bills a higher level of evaluation and management service to allow for the additional time. F N Explain: 3. Dr. Skeleton sets a simple fracture and puts a cast on Mr. Davis. He bills for a complex fracture F A N Explain: 4. A patient, Maria Gomez, asks a friendly staff member to change the dates on the insurance claim form. The medical assistant complies with the request. F A N Explain: 26 Chapter 3 Compliance, Fraud, and Abuse