CHOC Health Alliance’s (CHA) commitment to preventing, detecting, and correcting fraud, waste and abuse is a top priority. As part of this commitment, Providers / Medical Groups, and their employees are required to complete yearly Fraud, Waste & Abuse and General Compliance Training and attest that they have done so each year.
Fraud is generally defined as “knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program, or to obtain [by false or fraudulent pretenses, representations, or promises] any of the money or property owned by, or under the custody or control of any health care benefit program.” (18 USC § 1347)
Waste is overutilization of services, or other practices that result in unnecessary costs to the health care system. It is not generally considered to be caused by criminal negligence, but by the misuse of resources.
Abuse includes any actions that may, directly or indirectly result in one or more of the following:
- Unnecessary costs to the healthcare system (including Medicare and MediCal programs)
- Improper payment for services
- Payment for services that do not meet professionally recognize standards of care
- Providing medically unnecessary services
- Accepting payment for which there is no legal entitlement, without prior knowledge that a misrepresentation of facts or circumstances has occurred.
