FWA Awareness
At Meridian, we are dedicated to empowering providers with information essential for success in the critical role of caring for families. As part of our ongoing commitment to integrity and transparency, we want to take a moment to highlight the importance role you play in helping us prevent fraud, waste, and abuse (FWA).
Together, we can protect patients, ensure proper use of resources, and support the sustainability of programs.
What is Fraud, Waste, and Abuse?
Here is a quick overview of what these terms mean, along with a few examples.
Fraud
Fraud involves knowingly and willfully executing, or attempting to execute, a scheme to defraud any healthcare program or to obtain something of value through false or fraudulent representations.
Examples include:
- Billing for services not rendered
- Billing for a higher level of service than what was provided (upcoding)
- Billing for appointments the patient did not keep
Waste
Waste is the overutilization of services or misuse of healthcare resources, not caused by criminal conduct, but which results in unnecessary costs.
Examples include:
- Ordering unnecessary diagnostic tests
- Avoidable complications due to inefficient care
- Unnecessary hospital admissions
Abuse
Abuse refers to practices that are unintentionally or knowingly engaged in actions that are not aligned with accepted standards, resulting in unnecessary spending.
Examples include:
- Selecting codes that do not accurately reflect the services rendered.
- Billing component services instead of using the all-inclusive procedure code (unbundling)
- Upcoding to increase reimbursement
Here are key actions you can take to prevent FWA:
- Submit claims that accurately reflect services provided
- Ensure documentation supports medical necessity
- Avoid billing for items not ordered or not medically appropriate
- Keep up to date on current coding guidelines and payer requirements
- Train staff regularly on compliance and billing practices
- Report any concerns or suspected FWA through your organization’s compliance hotline or reporting system.
Preventing fraud, waste, and abuse goes beyond compliance, it is about protecting the entire healthcare ecosystem by protecting patients, reducing unnecessary spending, and preserving critical funding for programs like Medicare and Medicaid.
Your dedication to delivering quality care is appreciated, and we are here to assist in any way possible. Should you have more questions, need additional guidance, or encounter any challenges in implementing these recommendations, please do not hesitate to reach out.
Thank you for your ongoing commitment to excellence in healthcare.
Resources:
CMS Medicare Learning Network Booklet: Medicare Fraud & Abuse: Prevent, Detect, Report (PDF)
CMS Medicare Learning Network Web-Based Training (cms.gov)
U.S. Department of Health and Human Services Office of Inspector General - Compliance (oig.hhs.gov)
Michigan Department of Health and Human Services - Medicaid Provider Manual (PDF)