F
Definition
The overarching compliance framework mandated by CMS to prevent the misuse of Medicaid/Medicare funds.
Overview
Why it Matters
NEMT is a high-risk sector for FWA. Providers must have a compliance program to detect it, or risk prison time and heavy fines.
How it Works
Payers use data mining to look for outliers (e.g., a driver claiming to drive 25 hours in a day).
Code Comparison
Comparison: Fraud vs. Error
Fraud requires intent to deceive. Error is an honest mistake. A pattern of "errors" can be prosecuted as Fraud.
Common Questions
- Mileage Padding: Rounding 10.1 miles up to 11 miles repeatedly (most contracts require exact decimals or standard rounding).
- Family Drivers: Paying a driver to transport their own family member without disclosing the relationship.
- Conduct internal "Self-Audits" quarterly.
- Install cameras in vehicles to verify passenger presence.
Sources
CMS - Medicaid Program Integrity