Fraud, Waste & Abuse

LESSON 01

Understand the distinctions

Fraud involves intentional deception to obtain an improper benefit. Waste concerns unnecessary costs from inefficient or excessive use of resources. Abuse includes practices inconsistent with sound standards that create unnecessary costs or improper payments; it does not require the same proof of intent as fraud. An honest error is not automatically fraud, but still needs correction.

These distinctions guide attention, not amateur investigations. Interpreters rarely see an entire claim or contract. A service may be billed in units that differ from elapsed minutes, and cancellation or minimum charges may be legitimate. Record the facts you know and ask the appropriate billing contact to explain unfamiliar rules.

The useful habit is to separate observation from conclusion: “The voucher says I interpreted for two hours; I was there for one” is an observation. “Someone is stealing” is an accusation that may go beyond the evidence.

Sources: Centers for Medicare & Medicaid Services · Centers for Medicare & Medicaid Services

LESSON 02

Record what actually happened

Keep assignment identifiers, actual start and finish times, attendance, mode, and authorized expenses accurate. Use the designated correction process when a submitted entry is wrong. Preserve the difference between a service that occurred and an appointment that was canceled; do not invent an encounter to fit a payment category.

For a hypothetical 9:00–9:40 encounter, record the actual service facts. If the contract has a one-hour minimum, an authorized billing process may apply it separately. Do not silently change the finish time to 10:00. Keeping those concepts separate makes the record understandable to someone reviewing it later.

Never sign for another person or certify work you did not perform. If an electronic form will not accept the truthful facts, stop and ask for help rather than picking the nearest inaccurate option.

Sources: Centers for Medicare & Medicaid Services

LESSON 03

Recognize warning signs without assuming guilt

Examples worth reviewing include duplicate entries for the same service, appointments marked completed when nobody attended, pressure to conceal a cancellation, or a request to sign an unfilled voucher. A single irregularity may have an explanation. A repeated request to state something untrue is a reason to escalate.

Do not “fix” uncertainty by creating supporting details. If you do not remember whether an appointment ended at 2:10 or 2:20, consult the appropriate authorized record and correction procedure. A believable guess is still a guess.

Pressure may sound ordinary: “Everyone does it,” “The client asked for it,” or “It will be harder if you make a fuss.” Neither a busy schedule nor an instruction from a familiar person makes an inaccurate statement accurate.

• Check the original assignment before treating similar entries as duplicates.
• Keep factual notes about the discrepancy through an approved channel.
• Ask who is authorized to resolve contract or billing questions.

Sources: Centers for Medicare & Medicaid Services

LESSON 04

Respond to pressure calmly

A practical response is to describe the mismatch and the next step: “I can confirm the time I worked. Please have billing review the charge.” Avoid negotiating an alternative false entry, such as extra mileage in place of extra time.

If you are asked to approve something inaccurate, do not approve it while waiting for clarification. Ask the responsible contact how to leave it pending or correct it. If the person involved is the usual contact, use another authorized compliance or oversight route. Keep a record of the report according to the applicable procedure.

Sources: Centers for Medicare & Medicaid Services

LESSON 05

Report facts through appropriate channels

CMS encourages reporting suspected healthcare fraud, waste, or abuse. Internal compliance contacts, the relevant health plan, Medicare reporting channels, or HHS OIG may be appropriate depending on the concern. Use the official reporting pages linked below to identify the correct route; different programs handle different issues.

Provide the dates, service or record involved, what you observed, and how the record differs from what happened. State what you do not know. Do not access unrelated patient records or download an entire client database to gather evidence. Supply supporting material securely only as authorized or requested through the appropriate reporting process.

A public post or group chat is not a reporting channel. Confidentiality and accuracy continue to matter while a concern is reviewed.

Sources: Centers for Medicare & Medicaid Services · HHS Office of Inspector General

LESSON 06

Practice a clear discrepancy report

The aim is a report another person can act on without having to untangle opinion from fact. A calm account is more useful than a dramatic allegation. You can raise a concern without deciding which legal category ultimately applies.

Sources: Centers for Medicare & Medicaid Services