Medicare & Medicaid Fraud, Waste & Abuse

What Is Fraud, Waste, and Abuse? — CMS Definitions

Why FWA Training Is Required (42 CFR § 422.503 / § 423.504)

The Scale of the Problem — FWA by the Numbers

Fraud vs. Waste vs. Abuse — Key Distinctions

The False Claims Act (31 U.S.C. §§ 3729–3733)

FCA Civil Penalties — Per-Claim Fines and Treble Damages

Qui Tam Whistleblower Provisions and Protections

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))

AKS Safe Harbors — Permissible Arrangements

The Stark Law — Physician Self-Referral Prohibition

Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a)

Program Exclusions — OIG LEIE and SAM.gov Screening

Common Billing Fraud Schemes

Prescription Drug Fraud in Medicare Part D

Identity and Enrollment Fraud

Home Health and DME Fraud

Your Role in Preventing FWA

Documentation Standards and Medical Necessity

OIG 7 Elements of an Effective Compliance Program

OIG Compliance Program Guidance — By Provider Type

Internal Reporting Channels

External Reporting — OIG, CMS, FBI, State MFCU

Anti-Retaliation Protections for Whistleblowers

Consequences of Non-Compliance — Criminal, Civil, Administrative

Corporate Integrity Agreements (CIAs)

Voluntary Disclosure — OIG SDP and CMS Refund Process

The 60-Day Rule — Identifying and Returning Overpayments

Medicare Part D FWA Program Requirements

Practical Scenarios — What Would You Do?

Key Federal Agencies and Resources