Fraud generally is defined as an intentional deception or intentional misrepresentation that a person makes to gain a benefit for which that person is not entitled.
Examples of fraud in health care may include:
Abuse involves payment for items or services when there is no legal entitlement to that payment, and the health care provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Examples of abuse may include:
Waste is overutilization of services or other practices that, directly or indirectly result in unnecessary costs to the health care system. It is not generally considered to be caused by criminally-negligent actions but by payment errors, referred to as "improper payments," and the misuse of resources. Deficient management, practices, or controls can result in waste. Given the complexity of payment systems, waste is much more common than fraud and abuse.
Examples of waste may include:
Last Updated: 9/11/2014