Definition and Examples of Abuse

20.3.2 - Definition and Examples of Abuse (Rev. 1, 09-11-02) Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program. Many times abuse appears quite similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally. Following are three standards that CMS uses when judging whether abusive acts in billing were committed against the Medicare program: • Reasonable and necessary; • Conformance to professionally recognized standards; and • Provision at a fair price. Examples of abuse include, but are not limited to, the following: • Charging in excess for services or supplies; • Providing medically unnecessary services or services that do not meet professionally recognized standards; • Billing Medicare based on a higher fee schedule than for non-Medicare patients; • Submitting bills to Medicare that are the responsibility of other insurers under the Medicare secondary payer (MSP) regulation; and • Violating the participating physician/supplier agreement. Although these types of practices may initially be categorized as abusive in nature, under certain circumstances they may develop into fraud if there is evidence that the subject was knowingly and willfully conducting an abusive practice.