Commonwealth Care Alliance

Senior Care Options Program (HMO SNP)

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Definitions

Compliance and Fraud, Waste and Abuse Program Definitions

Fraud

Intentional deception or misrepresentation made by a person/entity with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person/entity.

Waste

The unintentional, thoughtless, or careless expenditures, consumption, mismanagement, use, or squandering of Commonwealth Care Alliance, federal, or state resources. Waste also includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, or controls.

Abuse

Practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to government programs or in reimbursement for services not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary costs to the Medicare/Medicaid programs.

Last Updated 07/29/2013