Which statement best describes fraud in medical billing?

• A. It involves unintentional misrepresentation.
• B. It is always a minor clerical error.
• C. It is the same as abuse.
• D. It involves intentional deception to obtain improper payment.

Answer: (D)

Fraud in medical billing is about intentional deception or misrepresentation to obtain payment that isn’t owed. The crucial element is intent to deceive for financial gain, not a simple mistake. That’s why unintentional misrepresentation isn’t fraud, and why a minor clerical error isn’t automatically fraud either. Fraud is distinct from abuse, which involves improper or questionable practices that may drive up costs but aren’t driven by a deliberate attempt to cheat the payer. Examples of fraud include billing for services not rendered, upcoding to a higher-paying code, falsifying diagnoses to justify payments, or double-billing.