What constitutes fraud in health care?

Fraud in health care is primarily defined by the intent to deceive for the purpose of obtaining an unauthorized benefit. This means that misrepresenting information—whether it involves falsifying patient records, exaggerating the necessity of services, or declaring services were rendered that were never provided—deliberately misleads payers or patients. This act results in financial gain from deceitful practices, which aligns directly with the definition of fraud.

The other options relate to errors or ethical missteps but do not typically meet the strict criteria for fraud. Accidentally billing for services not provided is often seen as a billing error rather than fraud since there is no intent to deceive. Similarly, providing services without a patient’s consent and billing for services that were overly charged could signal unethical practices or malpractice, but again, they lack the component of intentional deception for gain inherent in fraud. Thus, the act of misrepresenting information for unauthorized benefits is what definitively characterizes fraud in the context of health care.