Read through each scenario and circle/highlight whether it is a fraud (F) issue, the practice of abuse (A), or neither (N). 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 them or to some other person(s).

Briefly explain the answer you selected with the page # from the textbook.

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. 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 additional time.

3. Dr. Skeleton sets a simple fracture and puts a cast on Mr. Davis. He bills for a complex fracture. 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.

5. A patient, Roberto Loren, asks the physician to restate a diagnosis so the insurance company will pay because payment would be denied based on the present statement. The physician complies with the request.

6. Dr. Rumsey sees a patient twice on the same day but bills as though the patient was seen on two different dates.

7. A Medicare patient, Joan OConnor, is seen by Dr. Practon, and the insurance claim shows a charge to the Medicare fiscal intermediary at a fee schedule rate higher than and different from that of non-Medicare patients.

8. A patient, Hazel Plunkett, receives a service that is not medically necessary to the extent rendered, and an insurance claim is submitted. 9. 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.

10. Dr. Ulibarri tells the insurance biller not to collect the deductible and copayments from Mrs. Gerry Coleman.