How is abuse defined in Medicare billing?

• A. Practices that result in unnecessary costs to the Medicare program.
• B. Billing accurately for services.
• C. Providing services without consent.
• D. Charging services to patient only.

Answer: (C)

Abuse in Medicare billing refers to practices that are inconsistent with accepted medical practice and that lead to unnecessary costs to the Medicare program. It covers billing patterns that, while not always fraudulent, result in improper or excessive payments. For example, upcoding a service, billing for services not medically necessary, performing an excessive number of tests, or unbundling codes to obtain higher reimbursement. This concept focuses on the billing patterns and their impact on program costs, rather than on patient consent. Providing services without consent is primarily a patient rights/ethics issue and, if tied to billing, could involve fraud, but the standard definition of abuse centers on improper billing practices that increase costs.