Is This Fraud or an Educational Deficit?

FWA Healthcare Education

Is This Fraud or an Educational Deficit?

WHAT’S FRAUD, ANYWAY (AND WHAT ISN’T?)

According to the Centers for Medicare & Medicaid Services (CMS), fraud is knowingly submitting false claims or misrepresenting facts to get paid when you shouldn’t. It also covers things like paying for referrals to drum up more business. In short, fraud is intentional— and proving it takes a court of law. But here’s the twist: many cases don’t uncover criminal masterminds. Often, SIUs find mistakes & misunderstandings about coding rules. That’s where education comes in. If a provider is billing a code incorrectly, it could be a sign they need a refresher, not a courtroom summons. And if it’s a one-off error? That’s probably just being human.

WHY AN SIU SHOULD TAKE A PROVIDER - FRIENDLY APPROACH

Painful criminal and civil penalties are associated with healthcare fraud, waste and abuse (FWA). The consequences can be serious, and Special Investigations Units (SIUs) are on the front lines, working hard to spot FWA. But not every case is black and white. Sometimes, what looks suspicious is just a simple mistake or a knowledge gap. That’s why a provider-friendly approach isn’t just nice—it’s smart. It keeps relationships strong, networks healthy, and the focus where it belongs: on patient care and collaboration.

ASK YOURSELF: FRAUD OR FIXABLE FLUB? 

Before jumping to conclusions, SIUs can ask a few key questions: 

  • Is there clear, repeated disregard for coding rules? 

  • Are reports looking suspiciously “copy-pasted” with no patient-specific details? 

  • Has the provider been educated before, but nothing’s changed? 

    If the answer is ‘yes’ across the board, it might be time for a deeper look. If not, education could be the best medicine.

WASTE AND ABUSE: NOT ALWAYS A CRIME, BUT STILL A PROBLEM

Unlike fraud, waste and abuse do not require intent. They’re more about practices that lead to unnecessary costs—like incorrect coding, excessive service, or unbundling. These can still bring penalties, but they may be best handled with support and education to drive change, not necessarily punitive action.

SIZING UP THE SITUATION: WHAT’S NEXT?

To figure out the appropriate action, one should consider:

  • Is this a new problem for the provider?

    • New issues are great opportunities for education—especially if they’re tied to new staff, systems, or services. 

  • Is this a widespread issue?

    • If so, broader education (like newsletters or portal updates) might help everyone. 

HOW TO MAKE EDUCATION STICK

When it’s time to educate, a little planning goes a long way.

  1. Bring the right people to the table: providers, billing staff, techs... whoever’s involved.

  2. Develop and share an agenda to set expectations.

  3. Use real examples from the provider’s own records and peer comparisons in data.

  4. Link to all the relevant regulations, policies and resources.

  5. Set clear next steps, so everyone’s on the same page.

TOOLS OF THE TRADE

Providers have a lot to keep track of, and resources like the Medicare Learning Network (MLN) are there to help. SIUs can point providers to these tools for compliance tips and training, making it easier to stay on track. 

COLLABORATION IS KEY

At the end of the day, fighting FWA is a team sport. By sharing knowledge, offering support, and recognizing the challenges providers face, SIUs can build trust and keep the focus on what matters most: delivering great care. With a provider-friendly approach, SIUs can turn investigations into opportunities for growth and partnership— because sometimes, a little education is all it takes to turn confusion into compliance.

YOUR ONE-STOP-SHOP FOR HEALTHCARE FRAUD, WASTE, AND ABUSE SERVICES!

Want to learn more about how we help payers fight FWA? Reach out and let’s talk!

MLNICN4649244 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-AbuseMLN4649244.pdf

With more than 30 years of experience supporting payers, the team at Integrity Advantage provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and other organizations fighting healthcare fraud. We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).

For more information click below, call us at 866-644-7799 or email info@integrityadvantage.com.

Evie Mazzoccone