Fraud
Fraud is an intentional misrepresentation that may result in unauthorized costs to a healthcare program.

Waste
Waste is the inappropriate use of healthcare funds or resources without a justifiable need to do so.

Abuse
Abuse is a practice that is inconsistent with sound medical or business practices that may directly or indirectly result in unnecessary costs to a healthcare program.

There are differences between Fraud, Waste, and Abuse. These differences are based upon intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and Abuse may involve obtaining an improper payment but does not require the same intent and knowledge.

We expect everyone to report potential non-compliance including employees, contractors, and first-tier, downstream and related entities (FDRs). We’ve adopted and enforced a zero-tolerance policy for retaliation or intimidation against anyone who reports suspected misconduct. You may also choose to remain anonymous. If you are an FDR and you use your own code of conduct or compliance policies, you must include a process for reporting FWA issues that impact Gold Kidney.

Health care fraud, waste and abuse can take many forms, which makes it hard to spot. Here is a breakdown of the most common types.

Fraud

• Billing for service not rendered
• Falsifying a patients diagnosis to justify unnecessary procedures
• Accepting kickbacks for patient referrals

Waste

• Ordering excessive diagnostic tests
• Overuse of office visits
• A pharmacy sending medications to members without confirming they still need them

Abuse

• Charging in excess for services or supplies
• Providing medically unnecessary services
• Going to different doctors or emergency rooms to obtain pain medication