Fwa Case Study

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Recommended: Definition of Fraud

The Provider Manual summarizes the definitions of FWA set forth in 1 TAC §371.1 as follows: Waste is defined as activities “involving payment or the attempt to obtain payment…where there was no intent to deceive or misrepresent, but…poor or inefficient methods results in unnecessary costs” to Medicaid. Abuse is defined as activities “that unjustly enrich a person…but where the intent to deceive is not present,” or “an attempt…to unjustly obtain a benefit payment.” Finally, the Provider Manual defines fraud as “an intentional misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit….” If so, this investigation must include

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