Medicare Fraud, Waste, and Abuse Requirements: Policies, Training, and Reporting Best Practices

CMS eLearning Solutions

CMS eLearning Solutions provide structured modules that explain Medicare Fraud, Waste, and Abuse (FWA) requirements from policy to practice. You learn how FWA undermines program integrity and how targeted training supports improper payment reduction through better documentation, billing, and oversight.

Courses emphasize practical CMS policy interpretation, clarifying how guidance translates into day-to-day workflows. This helps program integrity personnel, compliance officers, and frontline staff align internal controls with Medicare rules without guesswork.

What you gain

• Foundational FWA concepts tied to claims submission, medical necessity, and beneficiary protections.
• Scenario-based decision making that shows how to prevent errors before they become patterns.
• Checklists for auditing, monitoring, and corrective action that strengthen program integrity.

National Correct Coding Initiative

The National Correct Coding Initiative (NCCI) promotes accurate Medicare Part B coding by bundling services that should not be billed together and flagging quantities that exceed norms. Using NCCI edits and Medically Unlikely Edits reduces denials, rework, and the risk of overpayments.

Building NCCI into your compliance program supports improper payment reduction while protecting legitimate revenue. Providers and coders avoid unbundling, misuse of modifiers, and duplicate billing that can trigger FWA investigations.

Best practices for NCCI use

• Automate pre-bill scrubs with current NCCI edits and review high-risk specialties and procedures.
• Validate modifier use with documentation that clearly supports distinct services or sites.
• Educate coders and clinicians together so documentation and coding reflect the same intent.

Medicaid Integrity Institute Training

The Medicaid Integrity Institute (MII) provides advanced education for state program integrity personnel focused on Medicaid claims compliance, analytics, investigations, and case development. While tailored to states, providers benefit by mirroring these techniques in internal audits and SIU work.

Topics such as data mining, sampling, and interview strategy help you spot aberrant billing early. Applying these disciplines to your Medicaid lines of business lowers risk and supports consistent CMS policy interpretation across payers.

Provider takeaways from MII disciplines

• Use data profiling to identify outliers by rendering provider, code, or geography.
• Build defensible samples and extrapolations for self-audits before payers do it for you.
• Document investigative steps to demonstrate good-faith compliance efforts.

AHIP Medicare FWA Training

AHIP Medicare FWA Training is widely used by Medicare Advantage and Part D sponsors and their first-tier, downstream, and related entities. It condenses statutory and regulatory expectations into role-based modules that you can implement quickly for new hires and annual refreshers.

The training reinforces code-of-conduct standards, reporting obligations, and the duty to cooperate with audits and investigations. It also helps align attestation, record retention, and vendor oversight practices that plans require from contracted entities.

How to maximize AHIP training

• Pair the course with organization-specific policies and case studies from your risk profile.
• Track completions and remediate knowledge gaps with targeted microlearning.
• Integrate reporting pathways for Medicare Advantage fraud reporting directly into the course wrap-up.

CMS National Training Program

The CMS National Training Program (NTP) offers curricula and webinars on Medicare fundamentals, coverage, and enrollment. NTP clarifies complex topics—such as coordination of benefits and appeals—so staff can provide accurate guidance and reduce avoidable errors that lead to recoupments.

By standardizing terminology and CMS policy interpretation across outreach teams, NTP helps beneficiaries, agents, and providers understand their responsibilities. Consistent communication lowers the likelihood of misinformation driving noncompliant claims behavior.

Using NTP effectively

• Embed NTP materials in onboarding for customer-facing teams and compliance ambassadors.
• Refresh training before annual enrollment periods when error risk spikes.
• Align FAQs and scripts with NTP language to ensure message consistency.

Reporting Suspected FWA

Establish clear, confidential channels so employees and contractors can report concerns without fear of retaliation. Encourage early reporting—patterns often begin as small anomalies in documentation, ordering, or billing.

Internal reporting workflow

• Document what you observed: dates, people involved, services, locations, and claim identifiers if available.
• Preserve evidence: notes, screenshots, and relevant records retained under legal hold.
• Notify compliance using your hotline or portal; escalate urgent patient-safety or large-dollar issues immediately.
• Initiate a preliminary review, segregate affected claims, and pause further billing if warranted.
• Decide on next steps: self-disclosure, repayment, education, or disciplinary action.

For plan sponsors and delegated entities, incorporate Medicare Advantage fraud reporting protocols so members and providers know when to contact the plan versus when to escalate externally.

Reporting FWA to Government Authorities

When internal review indicates potential fraud or systemic waste or abuse, report to appropriate authorities. Common options include your Medicare Advantage or Part D sponsor, state Medicaid agencies, and the Inspector General’s Hotline for serious allegations.

Escalation principles

• Report promptly once you have a good-faith basis and sufficient detail to describe the concern.
• Share only the minimum necessary information to protect patient privacy.
• Maintain a record of what was reported and any follow-up communications.
• Cooperate with requests for documents, interviews, or corrective action plans.

Summary

Effective Medicare Fraud, Waste, and Abuse programs blend clear policies, targeted training, and disciplined reporting. Leveraging CMS eLearning, NCCI, MII, AHIP training, and the CMS National Training Program equips teams to prevent errors, strengthen program integrity, and support improper payment reduction across Medicare and Medicaid operations.

FAQs

How do I report suspected Medicare fraud?

Use your organization’s compliance hotline first, then escalate to your Medicare Advantage or Part D plan if the issue involves plan activity. For serious or systemic concerns—especially those involving intentional deception—report to government authorities through the appropriate channels, including the Inspector General’s Hotline.

What training is required for Medicare fraud prevention?

Organizations typically provide general compliance and targeted FWA training covering policies, reporting obligations, documentation standards, and claims accuracy. Many entities use CMS eLearning, AHIP Medicare FWA Training, and CMS National Training Program resources, tailoring modules to roles and reinforcing requirements annually.

What information is needed when reporting fraud?

Provide specific facts: who was involved, what services or items were billed, when and where events occurred, claim or invoice identifiers, why the activity appears suspect, and any supporting documents. Include your contact information if you are willing to assist with follow-up.

How does the National Correct Coding Initiative reduce improper payments?

NCCI applies code-pair and quantity edits that prevent unbundling, duplicate billing, and excessive units, especially within Medicare Part B coding. Integrating NCCI into pre-bill edits and coder education lowers billing errors, curbs overpayments, and strengthens compliance controls.