What Is Abuse?

Abuse describes incidents or practices that are:

• not medically necessary as defined by Medicare guidelines; or 
• inconsistent with accepted sound medical, business or fiscal practices. 

Abuse occurs when individuals unintentionally follow practices that result in unnecessary Medicare Program costs. Abusive practices may develop into fraud or expose providers to civil or criminal liability.

Examples of abuse include:

• Misuse of codes billed ona  claim, such as unbundling charges or upcoding
• Submitting claims for unnecessary medical services 
• Charging excessively for services/supplies
• Incorrectly apportioning costs on cost reports
• Violation of the Medicare Participation agreement
• Routine waiver of coinsurance and deductibles
• Improper or sloppy billing practices

Revised 12/20/2024