Fraud is the intentional deception or misrepresentation that an individual (1) knows to be false or does not believe to be true and (2) makes knowing the deception could result in some unauthorized benefit to himself/herself or some other person.

Examples of fraudulent behavior:

• Altering claim forms to obtain a higher reimbursement amount (including billing Medicare for appointments that the patient failed to keep)
• Billing for services or supplies that were not provided (including billing for appointments beneficiaries neglected to keep)
• Billing both the beneficiary and Medicare for the same service/item
• Billing preadmission testing prior to a hospital admission that should be included in that diagnosis-related group (DRG) (i.e., global fee)
• Deliberately applying for duplicate reimbursement in order to get paid twice
• Completing Certificates of Medical Necessity (CMNs) for patients not personally and professionally known by the provider
• Unbundling or “exploding” charges
• Soliciting, offering, or receiving a kickback, bribe, or rebate
• False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc.
• Filing claims for services that are noncovered but billed as if they were covered services