Medicare Fraud, Waste, and Abuse Training

CMS Fraud, Waste, and Abuse (CMS FWA) Training is a critical compliance requirement for healthcare workers whose work involves Medicare or Medicaid. This course will help you recognize illegal practices and teach you how to prevent and report fraud, waste, or abuse.

What Is Included in CMS Fraud, Waste, and Abuse Training?  

CMS Fraud, Waste, and Abuse Training is a compliance course that explains how to recognize, prevent, report, and correct improper billing or misuse of Medicare and related healthcare funds.

In CMS FWA training, you’ll learn:

• The laws governing Medicare fraud, waste, and abuse (FWA),
• How to recognize FWA within healthcare billing,
• How to prevent and report FWA, and
• The consequences and penalties for Medicare FWA.

Anyone whose work touches Medicare or Medicaid administration or services will need CMS fraud, waste, and abuse training. From billing teams to front-office workers, you have a responsibility to prevent and report fraud, waste, or abuse if your role affects claims, billing, coverage decisions, or patient services.

Does CMS Require FWA Training?  

Yes – the Centers for Medicare & Medicaid Services (CMS) requires Fraud, Waste, and Abuse (FWA) training for people who work in Medicare Parts C and D environments, whether they work for a plan sponsor or a First-Tier, Downstream, or Related (FDR) entity.

When?

CMS requires qualified employees to complete FWA training within 90 days of hiring, contracting, or appointment to a new job function.

Refresher training should be provided at least once every 12 months, with additional specialized or refresher training provided:

• When requirements change,
• When employees are found to be noncompliant,
• As a corrective action to address a noncompliance issue, and/or
• When an employee works in an area implicated by past FWA.

Training records must be maintained for 10 years.

Who?

CMS requires FWA training for anyone whose jobs involve claims, billing, enrollment, pharmacy benefit administration, or beneficiary-facing services connected to Medicare, whether they’re an employee, contractor, temporary worker, volunteer, or governing body member.

CMS fraud, waste, and abuse training requirements apply to many types of organizations with FWA risk, including:

Medicare Advantage (MA) Employees. Those who work for MA administration in plan operations, member services, and other areas need training to manage FWA risks like approving improper services, mishandling claims, not catching upcoding or duplicate billing, or failing to detect member steering or marketing abuse.

Part D Plan Employees. Part D sponsor employees who manage prescription drug coverage need training to avoid FWA risks like prescription billing errors, inappropriate formulary decisions, drug diversion, false prior authorization activity, and improper reimbursement practices.

First Tier Entities. Employees of organizations that contract directly with MA or Part D sponsors – including prescription benefits managers (PBMs), claims processors, provider groups, sales vendors, and call centers – need training to manage high FWA risk from claims handling, enrollment, beneficiary communications, and delegated plan functions directly affecting Medicare payments and compliance.

Downstream Contractors. Employees of organizations that contract downstream of first-tier entities to carry out Medicare-related work like pharmacies, billing firms, marketing vendors, and credentialing companies need training to manage FWA risks like inaccurate claim submission, incomplete documentation, referral steering, and failure to follow rules that can create overpayments or violations.

Related Entities. Related entities are companies under common ownership or control with MA or Part D organizations that support operations by providing managed services, administrative support, leased property, or other shared services. Since they run key parts of the plan’s business and have access to sensitive information or systems, their employees need FWA training to prevent billing errors, improper conduct, and compliance failures.

Pharmacies and Pharmacy Benefit Managers (PBMs).Employees of pharmacies need training to manage FWA risk related to dispensing drugs and submitting prescription claims.Employees of PBMs need FWA training to manage risk related to managing drug benefits, claims processing, rebates, and formulary administration.

Penalties and Consequences

Failure to ensure required FWA training can expose organizations to corrective action requests and remediation plans that tie up organizational resources.

More importantly, undertrained or improperly trained staff expose organizations to Medicare compliance failures, leading to:

• Civil monetary penalties for violations or non-compliant conduct,
• Civil or criminal liability if the conduct rises to fraud,
• Exclusion from Medicare or Medicaid participation,
• Contract termination for plan sponsors or downstream entities, and/or
• Recovery of improper payments or overpaid claims.

What Is the Difference Between CMS Fraud, Waste, and Abuse?

The CMS defines fraud, waste, and abuse as separate categories of non-compliant behavior that lead to overpayment from Medicare funds. Specifically:

• Fraud involves intentionally gaining funds or assets through deception or misrepresentation. Examples include billing for services not provided, upcoding or unbundling services for higher reimbursement, and accepting or offering kickbacks for referrals.
• Waste increases costs through careless overuse, duplication, or inefficiency, even when no one intends to cheat. Examples include prolonged or inefficient workflows that increase costs without improving care, overstocking supplies that expire before use, or repeatedly failing to confirm coverage before providing services.
• Abuse includes behaviors that, even if unintentional, violate professional standards of conduct. Examples include poor documentation, billing for services that are not medically necessary, and submitting claims with errors that lead to improper payment.

CMS fraud, waste, and abuse all harm Medicare programs by driving up spending by the millions, resulting in higher program costs and less funds available for legitimate services. CMS fraud, waste, and abuse training helps teams identify red flags or bad patterns of conduct early and take actions to prevent compliance problems.

Examples of CMS FWA

There are many types of CMS fraud, waste, and abuse. Common examples include:

• Billing for Unprovided Goods or Services. Medicaid fraud schemes include upcoding medical procedures and charging for treatments and procedures that were not conducted. This leaves patients in the dark about the full scope of services rendered.
• Paying Kickbacks. A kickback occurs when a healthcare professional uses payment or other benefits to persuade a patient or another healthcare professional to recommend them to their office or institution.
• Billing for Medically Unnecessary Tests. Some providers scam patients by misrepresenting diagnoses and symptoms on patient records, then submitting invoices to insurance companies for higher reimbursement rates.
• Double Billing. When a provider is paid for the same service by several organizations, including insurance companies, pharmaceutical firms, insurers, or government programs, this is known as double-billing.
• Consumer Deception Fraud. Patients and consumers commit fraud by using insurance cards, identifying non-relatives, claiming unreceived services, and staging accidents.