Which statement best defines healthcare fraud?

• A. Intentional deception resulting in false claims
• B. Overutilization of services
• C. Medically unnecessary services beyond defensive medicine
• D. Billing errors due to clerical mistakes

Answer: (A)

Healthcare fraud hinges on deliberate deception to obtain payment. It involves knowingly submitting false claims or misrepresenting facts with the intent to defraud a payer. The crucial elements are intent and deception aimed at getting money or other benefits. Activities like overutilization or medically unnecessary services can be unethical or wasteful, but they aren’t fraud unless there’s evidence of intentional misrepresentation to obtain payment. Billing errors due to clerical mistakes are errors, not fraud, unless there’s proof of intentional falsification. So the best definition is intentional deception resulting in false claims.