The Differences between Fraud and Abuse (Essay Sample)

The Differences between Fraud and Abuse
Discuss the differences between fraud and abuse. During your discussion, research and describe a recent (within the last ten years) example and each outcome. Next, explain the desirable role of healthcare managers in fraud and abuse cases.
According to Buchbinder (2017), abuse refers to improper behaviors typically at odds with accepted standards or principles like good fiscal, commercial, or medical procedures. Fraud is defined as willful false representation or deception. Abuse can occur accidentally, whereas fraud is always intentional. Fraud and abuse have long been widespread throughout many businesses, especially in the healthcare sector. Fraudulent billing (charging for goods and services that have not been delivered) and getting kickbacks for referrals are just two instances. Abuse can take the form of overcharging for services or supplies or abusing codes on a claim, for example (Buchbinder, 2017). The annual cost of fraud and abuse in the U.S. healthcare system ranges from $125 to $175 billion (Sullivan & Hull, 2019).
Genesis Healthcare was charged with fraudulent billing in 2012, namely for false nursing care claims. It was claimed that Genesis Healthcare submitted false claims for unapproved or unneeded medical care by charging Medicare for hospice care given to patients who were not terminally ill at Skilled Healthcare Group, Skilled Healthcare, and Creekside Hospice. As a result, the Medicare hospice benefits were ineligible for the patients. It recently made a $53.6 million payment to the federal government to resolve bill and claim fraud problems. For instance, the settlement was predicated on a 2017 False Claims Act violation, specifically about the administration of medically unnecessary rehabilitative therapy in addition to hospice services (U.S. Department of Justice, 2017).