Directions: Read through each scenario and circle whether it is a fraud issue, practice of abuse, or neither. To distinguish the difference between fraud and abuse situations remember that under the Medicare program, abuse relates to incidents or practices that are inconsistent with accepted sound business practices, whereas fraud is intentional deception that an individual knows, or should know, to be false, and the individual knows the deception could result in some unauthorized benefit to himself or herself or to some other person(s). Explain the answer you selected.

Scenario:

A patient, Sun Cho, paid for services that were subsequently declared not medically necessary, and Dr. Cardi failed to refund the payment to the patient.

Question:

Is this a scenario of fraud issue, practice of abuse, or neither. Explain your answer.