Easy Care MSO (ECMSO) 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.* For this purpose, ECMSO has adopted a document published by CMS. Although the title of this training tool contains the words Medicare Parts C&D, the presentation is applicable to all lines of business.
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 Medi-Cal 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.
During an investigation, “fraud” (criminal) versus “abuse” determinations will depend on specific circumstances, such as available evidence, facts of the case, and the presence of intent.
For Fraud Waste and Abuse/ HIPAA or Security and Compliance/Noncompliance Concerns Contact:
Compliance Hotline: (562) 888-1415 Ext: 2911
Annual Compliance Programs:
- Standards of Conduct
- Fraud Waste and Abuse